Transporter-enhanced corticosteroid activity and methods and compositions for treating dry eye

ABSTRACT

Methods and compositions for enhancing the activity and/or duration of action of loteprednol etabonate and other soft anti-inflammatory steroids of the haloalkyl 17α-alkoxycarbonyloxy-11β-hydroxyandrost-4-cn-3-one-17β-carboxylate type and the corresponding Δ 1,4 -compounds are described. The enhancing agents have the formula: 
     
       
         
         
             
             
         
       
         
         
           
             wherein Z 1  is carbonyl, β-hydroxymethylene or methylene; R 2  is H, —OH or —OCOR 3  wherein R 3  is C 1-5  alkyl; Y is —OH, —SH or —OCOR 4  wherein R 4  is C 1-5  alkyl, cyclopentylethyl or diethylaminoethyl; and the dotted line in ring A indicates that the 1,2-linkage is saturated or unsaturated. Ophthalmic administration in the treatment of dry eye is specifically targeted.

CROSS-REFERENCE TO EARLIER APPLICATIONS

This application is a continuation-in-part of earlier copending U.S.patent application Ser. No. 11/802,403, filed May 2.2, 2007, whichclaims benefit under 35 U.S.C. 119(e) of U.S. Provisional ApplicationNo. 60/808,118, filed May 25, 2006, both earlier applications beingincorporated by reference herein in their entireties and relied upon.

BACKGROUND OF THE INVENTION

1. Technical Field of the Invention

The invention relates to enhancing the activity and/or the duration ofaction of particular anti-inflammatory steroids for topical or otherlocal application, including ophthalmic application for the treatment ofdry eye.

2. Background Art

Topical or other local application of potent glucocorticoids can producesevere toxic effects such as Cushingoid features, pituitary-adrenalsuppression, skin atrophy, immunosuppression, weight gain and inhibitionof wound healing. Other kinds of toxic responses, including allergiesand cataracts, have resulted from long term use of drugs of this type.

Ophthalmic application of glucocorticosteroids presents additionalproblems The protective mechanisms built into the eye allow only smallamounts of doses applied to the eye to reach the target sites within theeye; generally, over 90 percent of the total dose will find its way intothe general circulation. This in turn leads to serious systemic sideeffects of the type described above. Moreover, there is a more seriousand specific side effect when these drugs are used in the eye, which isan increase in intraocular pressure (IOP). Corticosteroid-inducedchronic or acute glaucoma has in fact been reported since the early1960's. Generally, the corticosteroid is needed only topically tocontrol the inflammation. However, the absorbed steroid is responsiblefor the serious side effects noted above. It is believed that the effectof the corticosteroid, on the aqueous outflow pathway and adjacent,tissue glycosaminoglycans (GAG's) is important in the development ofglucocorticoid-induced ocular hypertension.

The natural glucocorticosteroids and many of their marketed derivativesare Δ⁴ and Δ^(1,4) pregnenes having 21-hydroxy substituents. There are,however, a number of anti-inflammatory Δ⁴ and Δ^(1,4) androstenesdescribed in the literature; note, for example, British PatentSpecification No. 1,384,372; Phillipps et al. U.S. Pat. No. 3,828,080and Kalvoda et al. U.S. Pat. No. 4,285,937.

In recent years, soft steroids have been developed in an effort toprovide compounds having potent anti-inflammatory activity with minimalsystemic activity. One series of soft steroids which is described ashaving potent an anti-inflammatory activity with minimal systemicactivity consists of the 17α-carbonates of Bodor U.S. Pat. No.4,996,335. These compounds include as preferred embodiments haloalkyl17α-alkoxycarbonyloxy-11β-hydroxyandrost-4-en-3-one-17β-carboxylates andthe corresponding Δ^(1,4) compounds, optionally bearing 6α- and/or9α-fluorine and 16α- or 16β-methyl substituents. One of these compoundsis chloromethyl17α-ethoxycarbonyloxy-11β-hydroxyandrosta-1,4-dien-3-one-17β-carboxylate,also known as loteprednol etabonate. Loteprednol etabonate is presentlymarketed in the United States by Bausch & Lomb Pharmaceuticals, Inc. asAlrex® and Lotemax® and combined with tobramycin as Zylet® forophthalmic use. Other uses of loteprednol etabonate are currently inclinical trials (for rhinitis and various dermatological conditions).Mention is also made of Bartels United States Patent ApplicationPublication No. 2005/0222110, which describes the use of loteprednoletabonate itself for the treatment of dry eye, the contents of which isincorporated by reference herein in its entirety and relied upon;Pfugfelder et al.'s description of clinical trials utilizing 0.5%loteprednol etabonate suspension for treating keratoconjunctivitis sicca(Am. J. Opthalmol: 2004, 138(3), 444-457); and WO 03/030893, drawn tomethods of treating dry eye by administering combinations of MUC-1secretagogues, such as HETE derivatives, and anti-inflammatory steroids,one of which is loteprednol, this document also being incorporated byreference herein in its entirety and relied upon. See also OptometricManagement, February 2005 in which Dr. Ron Melton is quoted as saying“Loteprednol 0.5% has revolutionalized the way we treat dry eye”(accessed at http://www.optometric.com/article.aspx?article=71289 onJul. 12, 2007). Other publications relating to methods and compositionsfor treating dry eye utilizing loteprednol etabonate and compositionscomprising it include Meyering U.S. Patent Appln. Publication No.2005/0182039; Gamache et al. U.S. Patent Appln. Publication No.2006/0069075; Xia et al. U.S. Patent Appln. Publication No. 2006/0148686and Chappell et al. U.S. Patent Appln. Publication No. 2007/0105761, allincorporated by reference herein in their entireties and relied upon.

Despite the development of steroids having less systemic toxicity,however, there is a serious need for improvement in topical and otherlocal applications. The newer, less toxic, locally/topically activecompounds are more expensive to synthesize than the long-establishedcompounds. Moreover, the most potent anti-inflammatory steroids arethose which have substitution at the 6, 9 and/or 16-positions and thusalso not only are farthest removed structurally from the naturalcorticosteroids but also have the greatest toxicity. Thus, there is aneed for enhancing the activity or duration of action or both of the17α-carbonate type soft androstenes which lack the 6-, 9- and/or16-substitution pattern. Further, it would be desirable to allow thesesteroids to undergo easier metabolism and concentrate them at thedesired site of action.

One of the major, inactive metabolites of hydrocortisone is cortienicacid, i.e. 11β,17α-dihydroxyandrost-4-en-3-one-17β-carboxylic acidCortienic acid and the corresponding Δ^(1,4) acid have been previouslydescribed as synthetic intermediates useful in the preparation of thesoft steroids described in Bodor U.S. Pat. Nos. 4,710,495 and 4,996,335.The 17β-methyl, ethyl and isopropyl esters of Δ¹-cortienic acid havebeen described as putative inactive metabolites of the anti-inflammatoryandrostene derivatives of WO 97/42214 and Bodor U.S. Pat. No. 5,981,517.The '517 patent also describes the use of Δ¹-cortienic acid as acompetitor (with [3H]-triamcinolone acetonide as a tracer) for in vitroreceptor-binding studies of the androstene derivatives of that patentand notes similar studies of loteprednol etabonate. Druzgala et al., J.Steroid Biochem. Mole. Biol., Vol. 38, No. 2, pp 149-154 (1991), reportsearlier in vitro receptor binding studies of loteprednol etabonate andtwo putative metabolites, Δ¹-cortienic acid and the corresponding17α-ethyl carbonate, in a medium containing 10⁻⁵M cortienic acid ascompetitor, along with [3H]-triameimolone acetonide as tracer. Druzgalaet al. further note that loteprednol itself is intrinsically active,whereas the putative metabolites are indeed inactive. Neither theseacids nor their esters have been suggested as active ingredients for usein pharmaceutical compositions for the treatment of inflammation becausethey are not themselves active as anti-inflammatory agents. However,such inactive metabolites have been described as enhancing theanti-inflammatory activity and duration, of action of loteprednoletabonate and related soft steroids in Bodor United States ApplicationPublication No. 2005/0026892A1, published Feb. 3, 2005. Such inactivemetabolites have also been described as enhancing the anti-inflammatoryactivity and duration of action of selected other corticosteroids, forexample, hydrocortisone; see Bodor United States Application PublicationNo. 2005/0020551 A1, published Jan. 27, 2005.

Nevertheless, there remains a need for alternate methods andcompositions for enhancing the anti-inflammatory activity and durationof action of loteprednol etabonate and related soft, steroids.

SUMMARY AND OBJECTS OF THE INVENTION

It has now been found that hydrocortisone, prednisolone and relatedcompounds enhance the topical or other local activity or duration ofaction of selected soft anti-inflammatory steroids such as loteprednoletabonate.

Thus, in one aspect, the present invention provides a pharmaceuticalcomposition of matter comprising:

(1) a synergistic combination of:

-   -   (a) a compound having the formula:

wherein:

R₁ is C₁-C₇alkyl;

Z is carbonyl or β-hydroxymethylene;

X is Cl or F;

and the dotted line in ring A indicates that the 1,2-linkage issaturated or unsaturated; and

-   -   (b) a compound having the formula:

wherein:

Z₁ is carbonyl, β-hydroxymethylene or methylene;

R₂ is H, —OH or —OCOR₃ wherein R₃ is C₁-C₅ alkyl;

Y is OH, —SH or —OCOR₄, wherein R₄ is C₁-C₅ alkyl, cyclopentylethyl ordiethylaminomethyl;

and the dotted line in ring A indicates that the 1,2-linkage issaturated or unsaturated;

and wherein the compound of formula (II) is present in an amounteffective to enhance the anti-inflammatory activity or duration ofaction, or both, of said compound of formula (I); and

(2) a non-toxic pharmaceutically acceptable carrier therefor suitablefor topical or other local application.

In another aspect, the invention provides a combination comprising (a)and (b) above, in a combined synergistic anti-inflammatory effectiveamount, the amount of (b) being sufficient to enhance theanti-inflammatory activity or duration of action, or both, of (a).

It is understood that the compositions and combinations of the presentinvention do not comprise, and the methods of the present inventionlikewise do not encompass the administration of, a compound of theformula:

wherein:

R is H or C₁-C₄ alkyl;

Z₂ is carbonyl or β-hydroxymethylene;

X₁ is —O— or —S—;

R₅ is —OH, —OR₆, —OCOOR₆ or —OCOR₇ wherein R₆ is C₁-C₄ alkyl, and R₇ isC₁-C₄ alkyl, fluoromethyl or chloromethyl;

and the dotted line is defined as above;

with the proviso that when R is C₁-C₄ alkyl, then R₅ is —OH.

The compounds of formula (III) have been described as enhancers for thecompounds of formula (I) in Bodor United States Application PublicationNo. 2005/0026892A1.

Therefore, in another aspect, the invention provides the compositionsand combinations as described above but with the proviso that thecomposition or combination excludes a compound of formula (III), or withthe proviso that, the composition or combination comprises (a) and (b)above as the only steroids in the composition; or with the proviso thatthe molar ratio of the compound of formula (II) to the compound offormula (I) is from about 2:1 to about 0.05:1 (preferably from about 1:1to about 0.2:1, most preferably from about 1:1 to about 0.5:1). Theindicated ratios represent preferred embodiments. It is to be noted thatthe compound of formula (II) is present in a subtherapeutic amount.

In still a further aspect, the compositions described above areophthalmic compositions and the carrier is a non-toxic, ophthalmicallyacceptable one.

In another aspect, the present invention provides a pharmaceuticalcomposition of matter comprising:

(a) an anti-inflammatory effective amount of a compound having formula(I) as defined above;

(b) an amount of a compound of formula (II) as defined above sufficientto enhance the anti-inflammatory activity or duration of action, orboth, of said compound of formula (I); and

(c) a non-toxic, pharmaceutically acceptable carrier suitable fortopical or other local application;

with the optional provisos indicated hereinabove.

In yet another aspect, the invention provides a combination comprising:

(a) an anti-inflammatory effective amount of a compound having formula(I) as defined above; and

(b) an amount of a compound of formula (II) as defined above sufficientto enhance the anti-inflammatory activity or duration of action, orboth, of said compound of formula (I).

In a further aspect of the invention, there is provided a composition asdefined in the preceding paragraph in which the composition isophthalmic and the carrier is a non-toxic, ophthalmically acceptableone.

In yet another aspect, the present invention provides a method forenhancing the anti-inflammatory activity or duration of action, or both,of a compound having formula (I) as defined above following topical orother local administration of said compound to a warm-blooded animal toalleviate a topical or other localized (e.g. ophthalmic) inflammatoryresponse, said method comprising topically or otherwise locally (e.g.ophthalmically) co-administering said compound to said animal with asynergistically effective amount of a compound having formula (II) asdefined above, the amount of the compound of formula (II) beingsufficient to enhance the anti-inflammatory activity or duration ofaction, or both, of said compound of formula (I). Preferably, thecompounds are co-ad ministered in the form of one of the compositions ofthe invention defined above.

In still another aspect, the present invention provides a method fordecreasing the in vivo transcortin binding of an anti-inflammatorysteroid which binds to transcortin, and which is a compound havingformula (I) as defined above, and for thus enhancing theanti-inflammatory activity or duration of action, or both, of saidsteroid following topical or other local administration of said steroidto a warm-blooded animal to alleviate a topical or other localized (e.g.ophthalmic) inflammatory response, said method comprising topically orotherwise locally (e.g. ophthalmically) co-administering said steroid tosaid animal with an amount of a compound having formula (II) above whichis effective to decrease the in vivo transcortin binding of saidsteroid. Again, the compounds are preferably co-administered in the formof one of the compositions of the invention defined above.

Thus, the present invention provides a new use of a compound of formula(II) in the preparation of a medicament for treatment of topical andother local, inflammation, such as for treatment of ophthalmicinflammation; the compound of formula (II), while not itself havinguseful anti-inflammatory activity in the amount used, is employed, inaccord with the present invention to enhance the activity of ananti-inflammatory steroid having transcortin binding activity, andhaving formula (I) above, by combining the compound of formula (II) withthe active steroid of formula (I) in one of the compositions definedabove.

In yet other aspects of the invention, there are provided combinations,compositions and methods for enhancing the activity or duration ofaction, or both, of the compound of formula (I) for use in the treatmentof dry eye syndrome, a condition which is only partially inflammatory innature.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a graph of the variation in effect of hydrocortisone (0.1 mM)and prednisolone (0.1 mM) on the vasoconstriction activity ofloteprednol etabonate (0.1 mM) with time after removal, in hours.

FIG. 2 is a graph of the variation in the effect of hydrocortisone (1mM) and prednisolone (1 mM) on the vasoconstriction activity ofloteprednol etabonate (1 mM) with time after removal, in hours.

DETAILED DESCRIPTION OF THE INVENTION

Throughout the instant specification and claims, the followingdefinitions and general statements are applicable.

The patents, published applications, and scientific literature referredto herein establish the knowledge of those with skill in the art and arehereby incorporated by reference in their entirety to the same extent asif each was specifically and individually indicated to be incorporatedby reference. Any conflict between any reference cited herein and thespecific teachings of this specification shall be resolved in favor ofthe latter. Likewise, any conflict between an art-understood definitionof a word or phrase and a definition of the word or phrase asspecifically taught in this specification shall be resolved in favor ofthe latter.

As used herein, whether in a transitional phrase or in the body of aclaim, the terms “comprise(s)” and “comprising” are to be interpreted ashaving an open-ended meaning. That is, the terms are to be interpretedsynonymously with the phrases “having at least” or “including at least”.When used in the context of a process, the term “comprising” means thatthe process includes at least the recited steps, but may includeadditional steps. When used in the context of a composition, the term“comprising” means that the composition includes at least the recitedfeatures or components, but may also include additional features orcomponents.

The terms “consists essentially of” or “consisting essentially of” havea partially closed meaning, that is, they do not permit inclusion ofsteps or features or components which would substantially change theessential characteristics of a process or composition; for example,steps or features or components which would significantly interfere withthe desired properties of the compositions described herein, i.e., theprocess or composition is limited to the specified steps or materialsand those which do not materially affect the basic and novelcharacteristics of the invention. The basic and novel features hereinare the provision of a combination of a compound of formula (I) with acompound of formula (II) which enhances the activity and/or duration ofaction of (I) for topical or other local application in the treatment ofinflammation. In particular, the terms “consisting essentially of” or“consisting of” do not permit the inclusion of a compound of formula(III) above, i.e. an inactive metabolite enhancing agent, in thecombinations, compositions and methods of the present invention.

The terms “consists of” and “consists” are closed terminology and allowonly for the inclusion of the recited steps or features or components.

As used herein, the singular forms “a,” “an” and “the” specifically alsoencompass the plural forms of the terms to which, they refer, unless thecontent clearly dictates otherwise.

The term “about” is used herein to mean approximately, in the region of,roughly, or around. When the term “about” is used in conjunction with anumerical range, it modifies that range by extending the boundariesabove and below the numerical values set forth. In general, the term“about” or “approximately” is used herein to modify a numerical valueabove and below the stated value by a variance of 20%.

As used herein, the recitation of a numerical range for a variable isintended to convey that the invention may be practiced with the variableequal to any of the values within that range. Thus, for a variable whichis inherently discrete, the variable can be equal to any integer valueof the numerical range, including the end-points of the range.Similarly, for a variable which is inherently continuous, the variablecan be equal to any real value of the numerical range, including theend-points of the range. As an example, a variable which is described ashaving values between 0 and 2, can be 0, 1 or 2 for variables which areinherently discrete, and can be 0.0, 0.1, 0.01, 0.001, or any other realvalue for variables which are inherently continuous.

In the specification and claims, the singular forms include pluralreferents unless the context clearly dictates otherwise. As used herein,unless specifically indicated otherwise, the word “or” is used in the“inclusive” sense of “and/or” and not the “exclusive” sense of“either/or.”

As used herein, the term “subtherapeutic amount” means an amount belowthat expected to have a therapeutic effect in a givencombination/composition/method. A subtherapeutic amount can also bedefined as an amount of the compound of formula (II) which is itselfinsufficient to have an anti-inflammatory activity, that is,insufficient to provoke or cause an anti-inflammatory response. Actualamounts vary with the particular compounds involved. For example,loteprednol etabonate of formula (I) has approximately 20 times theactivity of hydrocortisone of formula (II). Therefore, a ratio of(II):(I) of 1:1 or 2:1 utilizes an amount of hydrocortisone (HC) whichhas only 1/10 or 1/20 the anti-inflammatory activity of the activeingredient loteprednol etabonate. Such an amount of FTC is effective asan enhancer of (I) but is not itself a large enough amount to betherapeutic. Rather, the amount is subtherapeutic.

Technical and scientific terms used herein have the meaning commonlyunderstood by one of skill in the art to which the present inventionpertains, unless otherwise defined. Reference is made herein to variousmethodologies and materials known to those of skill in the art. Standardreference works setting forth the general principles of pharmacologyinclude Goodman and Gilman's The Pharmacological Basis of Therapeutics,10^(th) Ed, McGraw Hill Companies Inc., New York (2001).

As used herein, “treating” means reducing, preventing, hindering orinhibiting the development of, controlling, alleviating and/or reversingthe symptoms in the individual to which a combination or composition ofthe invention has been administered, as compared to the symptoms of anindividual not being treated according to the invention. A practitionerwill appreciate that the combinations, compositions, dosage forms andmethods described herein are to be used in concomitance with continuousclinical evaluations by a skilled practitioner (physician orveterinarian) to determine subsequent therapy. Such evaluation will aidand inform in evaluating whether to increase, reduce or continue aparticular treatment dose, and/or to alter the mode of administration.

The methods of the present invention are intended for use with anysubject/patient that may experience the benefits of the methods of theinvention. Thus, in accordance with the invention, the terms “subjects”as well as “patients,” “individuals” and “warm-blooded animals” includehumans as well as non-human subjects, particularly domesticated animals,particularly dogs, cats, horses and cows, as well as other farm animals,zoo animals and/or endangered species.

The compounds of formula (II), while themselves much less active asglucocorticoids than the compounds of Formula (I) and most preferablyused herein as synergistic in amounts lower than amounts consideredtherapeutically effective, are able to enhance the glucocorticoidactivity and/or duration of glucocorticoid action of the compounds offormulas (I) by competing with them in vivo for transcortin bindingsites. The addition of the compound of formula (II) hinders efflux awayfrom the site of local administration (which is also the site of action)of the active anti-inflammatory compound of formula (I) by competingwith the active compound for various in vivo systems which transportaway from the site. This thus contributes to an increase in the amountof free active compound available at the desired site ofaction/administration or increases the time that the active compoundremains at the site, or both. Further details of this mechanism ofaction are set forth later in this document.

With respect to the various groups encompassed, by the generic termsused here and throughout the specification, the definitions andexplanations given below are applicable.

R₁ is a straight or branched-chain alkyl radical having 1 to 7 carbonatoms, preferably 1 to 4 carbon atoms, such as methyl, ethyl, n-propyl,isopropyl, isobutyl and n-butyl

Z is carbonyl or β-hydroxymethylene, preferably β-hydroxymethylene.

X is chloro or fluoro, preferably chloro.

Z₁ is carbonyl or β-hydroxymethylene or methylene, preferablyβ-hydroxymethylene.

R₂ is hydroxy or —OCOR₃ wherein R₃ is straight or branched-chain alkylhaving 1 to 5 carbon atoms, preferably 1 to 4 carbon atoms, such asmethyl, ethyl, n-propyl and n-butyl. Preferably, R₂ is hydroxy,—OCOCH₂CH₃, —OCOCH₂CH₂CH₃ or —OCO(CH₂)₃CH₃.

Y is —OH —SH or —OCOR₄ wherein R₄ is straight or branched alkyl of 1 to5 carbon atoms, cyclopentylethyl or diethylaminomethyl; Y is preferably—OH, —OCOCH₃, —OCOCH₂CH₃ or —OCOC(CH₃)₃.

The dotted line in formulas (I) and (II) indicates that the A-ring canhave the Δ⁴ or Δ^(1,4) configuration. In the case of the compounds offormula (II), there is a preference for the structural variables,including the presence or absence of a 1,2-double bond, which correspondto those of corticosteroid, cortisol (hydrocortisone),11-deoxycorticosterone, 11-deoxycortisol, prednisolone and Cortisolacetate, especially hydrocortisone and prednisolone. In the case ofcompounds of formula (I), it is most preferred that the structuralvariables, including the presence or absence of a 1,2-double bond,correspond to those of loteprednol etabonate.

The compounds of formula (I) above are described in Bodor U.S. Pat. No.4,996,335, incorporated by reference herein in its entirety and reliedupon. Specific compounds of formula (I) disclosed in that patent andrepresentative of compounds of formula (I) for use herein include thefollowing:

-   1. chloromethyl    17α-ethoxycarbonyloxy-11β-hydroxyandrosta-1,4-dien-3-one-17β-carboxylate,    also known as loteprednol etabonate or LE;-   2. chloromethyl    11β-hydroxy-17α-methoxycarbonyloxyandrost-4-en-3-one-17β-carboxylate;-   3. chloromethyl    17α-ethoxycarbonyloxy-11β-hydroxyandrost-4-en-3-one-17β-carboxylate;-   4. chloromethyl    17α-buloxycarbonyloxy-11β-hydroxyandrost-4-en-3-one-17β-carboxylate;-   5. chloromethyl    11β-hydroxy-17α-isopropoxycarbonyloxyandrost-4-en-3-one-17β-carboxylate;-   6. chloromethyl    11β-hydroxy-17α-isopropoxycarbonyloxyandrost-1,4-dien-3-one-17β-carboxylate;-   7. chloromethyl    11β-hydroxy-17α-isobutoxycarbonyloxyandrost-4-en-3-one-17β-carboxylate;-   8. chloromethyl    11β-hydroxy-17α-propoxycarbonyloxyandrost-4-en-3-one-17β-carboxylate;-   9. fluoromethyl    11β-hydroxy-17α-isopropoxycarbonyloxyandrost-4-en-3-one-17β-carboxylate;-   10. chloromethyl    11β-hydroxy-17α-n-propoxycarbonyloxyandrosta-1,4-dien-3-one-17β-carboxylate;    and-   11. chloromethyl    11β-hydroxy-17α-methoxycarbonyloxyandrosta-1,4-dien-3-one-17β-carboxylate.

An especially preferred compound of formula (I) for use in the presentinvention is chloromethyl17α-ethoxycarbonyloxy-11β-hydroxyandrosta-1,4-dien-3-one-17β-carboxylate,or loteprednol etabonate. Loteprednol etabonate and other preferredcompounds of formula (I) are those in which R₁ is methyl, ethyl,n-propyl, isopropyl, n-butyl or isobutyl, X is chloro, and Z isβ-hydroxymethylene, most especially when the 1,2-linkage is unsaturated.These and other compounds of formula (I) can be prepared by methodsdescribed in the aforementioned '335 patent.

The compounds of formula (II) above are well-known anti-inflammatorysteroids described in various patent and non-patent documents.Representative compounds include cortisone, cortisone acetate,hydrocortisone (cortisol), hydrocortisone acetate (cortisol acetate),hydrocortisone aceponate, hydrocortisone butyrate, cortisone21-cyclopentanepropionate, hydrocortisone 21-cypionate, hydrocortisonevalerate, prednisolone, prednisolone acetate, prednisolone tebutate(21-tert-butylacetate), prednisolone 21-pivalate (21-trimethylacetate),prednisolamate (prednisolone 21-diethylaminoacetate), prednival(prednisolone 17-valerate), prednisone, prednisone 21-acetate,corticosterone, tixocortol, corticosterone 21-acetate, hydrocortamate,11-deoxycorticosterone, 11-deoxycortisol (11-deoxyhydrocortisone),prednicarbate and hydrocortisone tebutate (hydrocortisone21-tert-butyl-acetate). The structures of these compounds are shown inthe following TABLE 1 below.

TABLE 1 Compound of Formula (II) Z₁ Δ R₂ Y cortisone

4 —OH —OH cortisoneacetate

4 —OH —OCOCH₃ hydrocortisone(cortisol)

4 —OH —OH hydrocortisoneacetate(cortisolacetate)

4 —OH —OCOCH₃ hydrocortisoneaceponate

4 —OCOCH₂CH₃ —OCOCH₃ hydrocortisonebutyrate

4 —OCOCH₂CH₂CH₃ OH cortisone 21-cyclopentane-propionate

4 —OH

hydrocortisonecypionate

4 —OH

hydrocortisonevalerate

4 —OCO(CH₂)₃CH₃ —OH prednisolone

1,4 —OH —OH prednisolamate

1,4 —OH —OCOCH₂N(C₂H₅)₂ prednisoloneacetate

1,4 —OH —OCOCH₃ prednisolonetebutate

1,4 —OH —OCOCH₂C(CH₃)₃ prednisolone21-pivalate

1,4 —OH —OCOC(CH₃)₃ Prednival

1,4 —OCO(CH₂)₃CH₃ —OH prednisone

1,4 —OH —OH prednisone21-acetate

1,4 —OH —OCOCH₃ corticosterone

4 —H —OH tixocortol

4 —OH —SH corticosterone21-acetate

4 —H —OCOCH₃ hydrocortamate

4 —OH —OCOCH₂N(C₂H₅)₂ prednicarbate

1,4 —OCOC₂H₅ —OCOC₂H₅ hydrocortisonetebutate

4 —OH —OCOCH₂C(CH₃)₃ 11-deoxy-corticosterone

4 —H —OH 11-deoxycortisol

4 —OH —OH

In the compositions and methods of the present invention, the enhancingagent of formula (II) and compound of formula (I) are generally used ina molar ratio of from about 2:1 to about 0.05:1 (preferably from about1:1 to about 0.2:1, even more preferably from about 1:1 to about 0.5:1),that is, from about 0-05 to about 2 moles (preferably from about 0.2 toabout 1 mole) of the formula (II) compound for each mole of compound offormula (I). In situations in which the molecular weight of the formula(II) compound is similar to that of the selected compound of formula(I), a weight/weight ratio of from about 2:1 to about 0.05:1 (preferably0.2:1 to 1:1, approximately) will closely approximate the about 2:1 toabout 0.05:1 (preferably about 0.2:1 to about 1:1) molar ratio and canbe used instead for ease in formulating pharmaceutical formulations.Indeed, even when the molecular weight of the compound of formula (I) is10-20% greater than that of the formula (II) compound, the about 2:1 toabout 0.05:1 (II):(I) (preferably about 0.2:1 to about 1:1) weight ratiocan be conveniently employed.

The rationale for the present combination of compounds of formula (I)and (II) is as follows:

There are two major specific receptors important for corticosteroidactivity. One is the glucocorticoid receptor (GCR or GR), whichquantitates the relative intrinsic activity, as the relative strengthsfor binding to this receptor. The GCR is ubiquitous, that is, it isfound in essentially every cell, so systemic steroids (either bysystemic administration or by distribution from local application) willproduce systemic effects, many of them unwanted. This receptor (GCR) isresponsible for the ACTIVITY. Of course, by definition, the more potent,glucocorticoids replace weaker ones on this specific receptor. Actually,this is the basis of measuring their relative activities.

The second receptor involved in many of the glucocorticoids is theso-called Corticosteroid Binding Globulin (CBG), which is also calledtranscortin. This again specifically binds corticosteroids andtransports them in the general circulatory system to different sites.This is a specific binding, but one that is not responsible foractivity.

The present inventor has found that the relative binding to the twospecific receptors, GCR and CBG, do not run parallel. Some compoundswith weak activity (low GCR binding), bind strongly to transcortin (CBG)Interestingly, however, while all corticosteroids bind to GCR, only ahandful of them bind effectively to transcortin

The following table shows the GR (GCR) relative binding affinities of anumber of representative glucocorticosteroids for the GCR. As can beseen from this table, compounds such as hydrocortisone and its estersand prednisolone, which are representative of the compounds of formula(II), have much lower GCR values than loteprednol etabonate, arepresentative compound of formula (I).

RBA of Representative Glucocorticoids for the GCR (GR)

Compound Formula logP rBA^(a) Ref Beclomethasone C₂₂H₂₉Cl₀₁O₀₅ 2.36^(b)76 [1] Beclomethasone 17- C₂₅H₃₃Cl₀₁O₀₆ 3.63 1440 [2, 3] monopropionateBeclomethasone dipropionate C₂₈H₃₇Cl₀₁O₀₇ 4.40 140 [2, 3] BetamethasoneC₂₂H₂₉F₀₁O₀₅ 1.94 79 [4-7] Budesonide, 22R C₂₅H₃₄O₀₆ 3.24 1120 [8]Budesonide, 22S C₂₅H₃₄O₀₆ 3.24 420 [8] Ciclesonide C₃₂H₄₄O₀₇ 5.14^(b) 15[9, 10] Ciclesonide, act. metab. C₂₈H₃₈O₀₆ 3.87^(b) 1681 [9, 10]Clobetasol propionate C₂₅H₃₂Cl₀₁F₀₁O₀₅ 3.83 6300 [7] CorticosteroneC₂₁H₃₀O₀₄ 1.94 35 [4, 5, 8] Dexamethasone C₂₂H₂₉F₀₁O₀₅ 1.83 100Etiprednol dicloacetate (BNP- C₂₄H₃₀Cl₀₂O₀₆ 4.44^(b) 200 [11] 166)Flunisolide C₂₄H₃₁F₀₁O₀₆ 2.28 165 [2, 3] Fluticasone propionateC₂₅H₃₁F₀₃O₀₅S₀₁ 4.20 1796 [1-3, 10, 12-14] Hydrocortisone (cortisol)C₂₁H₃₀O₀₅ 1.61 10 [4, 6, 8] Hydrocortisone 17-acetate C₂₃H₃₂O₀₆ 2.30 41[5] Hydrocortisone 17-butyrate C₂₅H₃₆O₀₆ 3.18 95 [5] Hydrocortisone17-propionate C₂₄H₃₄O₀₆ 2.70 79 [5] Loteprednol etabonate C₂₄H₃₁Cl₀₁O₀₇3.03 150 [15, 16] Mometasone C₂₂H₂₈Cl₀₂O₀₄ 3.11^(b) 88 [14] Mometasonefuroate C₂₇H₃₀Cl₀₂O₀₆ 4.53^(b) 1833 [3, 7, 12-14] Prednisolone C₂₁H₂₈O₀₅1.62 19 [4, 6, 7, 17] Triamcinolone C₂₁H₂₇F₀₁O₀₆ 1.16 45 [5, 18]Triamcinolone acetonide C₂₄H₃₁F₀₁O₀₆ 2.53 270 [1, 4-6, 8, 12]^(a)Relative receptor binding affinities are for the glucocorticoidreceptor and are relative to dexamethasone as reference (rRBA_(Dex) =100). Average of all values was used if multiple values were available.^(b)Calculated logP is given where no logP is reported in literature

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While the glucocorticoid receptor (GR, or GCR) is the main receptor thatmediates glucocorticoid activity and is a major determinant oftherapeutic potential which is related to, for example, the clinicalefficacy of inhaled glucocorticoids, to side-effects such as cortisolsuppression, to immunosuppressive potency, etc., transcortin or CBG is atransport/cargo protein which binds biologically active steroids withmuch higher affinity and specificity than other plasma proteins and is amajor detriment of steroid bioavailability. CBG binding influencesactivity because only the unbound fraction of the corticosteroidexercises activity.

The following table shows the CBG binding affinities of a number ofsteroids which appear in the scientific literature. Those in Class 1have the highest binding activity; of the Class 1 members, those whichare glucocorticoids, that is anti-inflammatory steroids, are of thegreatest interest to the present invention.

GBC Binding Affinities Compound Log 1/K Class aldosterone −6.279 2androstanediol −5.000 3 5-androstenediol −5.000 3 4-androstenedione−5.763 3 androsterone −5.613 3 corticosterone −7.881 1 cortisol(hydrocortisone) −7.881 1 cortisone −6.892 2 dehydroepiandrosterone−5.000 3 11-deoxycorticosterone −7.653 1 11-deoxycortisol −7.881 1dihydrotestosterone −5.919 2 estradiol −5.000 3 estriol −5.000 3 estrone−5.000 3 etiocholanolone −5.225 3 pregnenolone −5.225 317α-hydroxypregnenolone −5.000 3 progesterone −7.380 117α-hydroxyprogesterone −7.740 1 testosterone −6.724 2 prednisolone−7.512 1 cortisolacetat −7.553 1 4-pregnene-3,11,20-trione −6.779 2epicorticosterone −7.200 1 19-nortestosterone −6.144 2 16α,17α- −6.247 2dihydroxyprogesterone 16α-methylprogesterone −7.120 1 19-norprogesterone−6.817 2 2α-methylcortisol −7.688 1 2α-methyl-9α-fluoro- −5.797 2cortisolGBC binding activity data after. J. Am. Chem, Soc. 1988 110, 5959 and J.Med Chem. 1993, 36, 433. Activity classes 1: high, 2: intermediate, 3:low.

Experiments were undertaken to determine specific CBG (transcortin)binding values for a number of glucocorticoids and IC₅₀-values werecalculated.

Experimental procedure: Venous blood was collected from healthyvolunteers into heparin-containing tubes (5 Us/100 ml serum) and cellswere separated from plasma by centrifugation (1500 g for 15 min). Theplasma was treated with charcoal suspension (Harvey et al., J. SteroidBiochem 7: 55, 1976) in order to remove endogenous steroids.Charcoal-treated plasma was diluted 100-fold with binding buffer (10 mMTris-HCl; 2 mM DTT (dithiotreitol); 1.5 mM EDTA; 0.02 M Na₂MoO₄; 10%Glycerol; pH 7.4) and was stored aliquoted at −80° C., Binding of³H-cortisol (69.0 Ci/mmol, Amersham Biosciences), was determined usingthe charcoal adsorption procedure, as described previously by Korenmann(Steroids 13: 163, 1976). Briefly: aliquots (0.3 ml) of diluted serumwere added to assay tubes containing 3 nM ³H-cortisol alone orcontaining various concentrations of unlabeled steroid competitors.Non-specific binding was defined using 500-fold excess of unlabeledcortisol. The assay ingredients were mixed and the tubes were incubatedfor 1 hour on ice. At the end of the incubation, 0.2 ml of charcoalsuspension (0.5% Norit A and 0.05% BSA) was added to each tube. Thetubes were briefly agitated and incubated for an additional 10 min at 0°C. They were then centrifuged for 10 min at 15 000 g, and the samealiquots from the clear supernatants were quantitatively decanted intocounting vials and combined with 3 ml of toluene-based scintillationfluid. Radioactivity was determined by a Wallac LKB 1410radiospektro-fluoriméter. Specific binding and IC₅₀-values werecalculated.

Results: are shown in Table 2.

TABLE 2 Binding of different corticosteroids to transcortin (IC₅₀ nM)IC₅₀-values (nM) Compound average ± SEM (n) Cortisol

 69 ± 8 (12) Prednisolone

   6.7 ± 1.6 (3) Prednisone

 36 ± 11 (3) EtiprednolDicloacetate

4502 ± 973 (4) Loteprednoletabonate

 272 ± 27 (4) Cortienic acid(CA)GYKI-24805

 117 ± 49 (4) CA-MeGYKI-25806

   5.9 ± 1.4 (4) Δ1-CAGYKI-24762

 52 ± 10 (3) Δ1-CA-MeGYKI-24776

 31 ± 11 (3)

The present inventor has observed that GR and CBG affinities do not runin parallel. The following table graphically illustrates this point.

GR versus CBG Affinities GR and CBG binding affinities do not run inparallel GR Est. IC₅₀ CBG Est. IC₅₀ Compound (nM) (nM) prednisolone (PR)30 7 Δ¹-CA, methyl ester (Δ¹-CA, Me) >1000 30 Δ¹-cortienic acid(Δ¹-CA) >1000 50 cortisol (hydrocortisone, HC) 67 70 cortienic acid(CA) >1000 120 loteprednol etabonate (LE) 4 270 budesonide (BUD)0.9 >10000 ciclesonide, act. met. (CIC-AM) 0.5 >10000 fluticasonepropionate (FP) 0.4 >10000 mometasone furoate (MF) 0.4 >10000 Bodor, N.;Kuruez, I. 2006, unpublished results. Note: GRs were calculated fromRBAs.

Glucocorticoid activity, as represented by GR affinity, has thus beenfound not to parallel transcortin binding, as represented by CBGaffinity. The present invention makes use of this lack of parallel.Since lower IC₅₀'s's represent greater activity, the most activeglucocorticoids have the lowest GR Est. IC₅₀'s in the above table, whilethose binding most strongly to transcortin have the lowest CBG Est.IC₅₀'s. Hydrocortisone, the natural corticosteroid, and relatedcompounds (such as the hydrocortisone esters) bind very well totranscortin, although they are weak glucocorticoids. It appears that theprednisolone class (with one additional double bond in the C1-C2position), binds even more strongly. These compounds are strongtranscortin binders, significantly better than the much more potentloteprednol. Substituents such as 6-fluoro, 6-methyl, 9-fluoro etc. verymuch reduce transcortin binding, so such compounds cannot be similarlyenhanced.

While the combination with cortienic acid (CA), Δ¹ CA and esters areeffective CBG binders, although totally inactive, such are new,virtually unstudied compounds. The current invention, however, selectscombinations of potent GCR binding steroids, which have weak CBGbinding, with the reverse properties, that is with weak GC-s which arestrong transcortin binders. For example, the relatively weakhydrocortisone (HC), or weaker cortisone, also prednisone andprednisolone (PRN), which have much higher CBG binding properties, incombination with the much more potent loteprednol etabonate (LE), yielda significant, enhancement, of the local (skin, nose, lung, colon, etc.)activity, by virtue of effecting transport, away of LE, withoutproducing airy local or systemic contribution to the desired GCactivity. The studies below clearly demonstrate the enhancement of theactivity (extent and time) of LE on human skin, when combined withequivalent amounts of TIC or PRN. HC or PRN alone do not yield airydetectable activity. See Table 3 and FIGS. 1 and 2.

Thus, the pharmacological activity of a glucocorticoid that binds to CBGcan be strongly enhanced and its duration of action prolonged by mixingit with another steroid that has stronger affinity for CBG. If thesecond compound has no strong GR activity, it is not expected to causeany unexpected GR-related side effects. For example, the activity of thesoft steroid loteprednol etabonate, which binds to CBG, is stronglyincreased and prolonged by combining it with hydrocortisone orprednisolone.

The compounds of formulas (I) and (II) can be combined with suitablenon-toxic pharmaceutically acceptable earners to provide pharmaceuticalcompositions for use in the treatment of topical or other localizedinflammation. Obviously, in view of their lack of systemic activity,compositions containing the compounds of formula (I) are not intendedfor treatment of conditions where systemic adrenocortical therapy isindicated, e.g., adrenocortical insufficiency. As examples ofinflammatory conditions which can be treated with pharmaceuticalcompositions containing the combination of a compound of formula (I) anda compound of formula (II) and one or more pharmaceutical carriers, thefollowing can be mentioned: dermatological disorders such as atopicdermatitis, acne, psoriasis or contact dermatitis; allergic states suchas bronchial asthma; ophthalmic and otic diseases involving acute andchronic allergic and inflammatory reactions (for example, ophthalmicinflammatory conditions such as blepharitis, conjunctivitis,episcleritis, scleritis, keratitis, anterior uveitis and sympatheticophthalmia, including ophthalmic conditions which are only partiallyinflammatory in nature including in particular “dry eye” syndrome, alsoknown as keratoconjunctivitis sicca (KCS), and ear inflammations of theouter and middle ear as well as inflammation of the inner ear, forexample Meniere's Disease, injected or instilled into the inner earthrough the ear drum analogous to the current use of dexamethasone);respiratory diseases; inflammations of the mouth, gums and/or throat,such as gingivitis or oral aphtha; inflammations of the nasal mucosa,for example, those caused by allergies; inflammations of the upper andlower intestines, such as Crohn's disease and ulcerative colitis;inflammations associated with arthritis; and anorectal inflammation,pruritus and pain associated with hemorrhoids, proctitis, cryptitis,fissures, postoperative pain and pruritus am. Such compositions may alsobe applied locally as a prophylactic measure against the inflammationand tissue rejection which arise in connection with transplants.

Obviously, the choice of carrier(s) and dosage forms will vary with theparticular condition for which the composition is to be administered.

Examples of various types of preparations for topical/localadministration include ointments, gels, lotions, creams, powders, drops(e.g., eye or ear or nose drops), sprays (e.g., for the nose or throat),suppositories, retention enemas, chewable or suckable tablets or pellets(e.g., for the treatment of aphthous ulcers) aerosols, tablets andcapsules, and solutions (e.g., mouthwashes for treatment of inflammationof the oral cavity, especially the mouth or gums).

Ointments and creams or gels may, for example, be formulated with anaqueous or oily base with the addition of suitable thickening and/orgelling agents and/or glycols. Such base may thus, for example, includewater and/or an oil such as liquid paraffin or a vegetable oil such asarachis oil or castor oil, or a glycolic solvent such as propyleneglycol or 1,3-butanediol. Thickening agents which may be used accordingto the nature of the base include soft paraffin, aluminum stearate,cetostearyl alcohol, polyethylene glycols, woolfat, hydrogenated lanolinand beeswax and/or glyceryl monostearate and/or non-ionic emulsifyingagents.

The solubility of the steroids in the ointment or cream may be enhancedby incorporation of an aromatic alcohol such as benzyl alcohol,phenylethyl alcohol or phenoxyethyl alcohol.

Lotions may be formulated with an aqueous or oily base and will ingeneral also include one or more of the following, namely, emulsifyingagents, dispersing agents, suspending agents, thickening agents,solvents, coloring agents and perfumes.

Powders may be formed with the aid of any suitable powder base e.g.,tale, lactose or starch.

Drops may be formulated with an aqueous base also comprising one or moredispersing agents, suspending agents or solubilizing agents, etc.

Spray compositions may, for example, be formulated as aerosols with theuse of a suitable propellant, e.g., dichlorodifluoromethane ortrichlorofluoromethane.

Nebulized or powdered formulations may be prepared for oral inhalationin the treatment of asthma, as is well-known in the art.

Solutions and suspensions may be prepared for oral or rectaladministration for use in the treatment of inflammations of theintestines, for example, as described in more detail in the exampleshereinafter. Moreover, tablets, capsules and other oral dosage forms maybe used, for example, in the treatment of Crohn's disease, providedthat, they are formulated for delayed release (such as three hours afteradministration) to protect the compounds of formulas (I) and (II) fromgastric juice and to thus allow them to reach the target site, such asthe duodenum, before dissolving.

Parenteral/injectable formulations may be prepared for direct injectioninto the joints in the treatment of arthritis in accord with methodswell-known to those skilled in the art of parenteral formulations.

The combinations of the present invention can be incorporated intonanospheres or microspheres in a variety of dosage forms (oral, topical,inhalation, etc.) to provide sustained/controlled release of thecompounds of formulas (I) and (II) to treat various inflammatoryconditions and/or in the case of dermal or transdermal patchescontaining the combinations so incorporated, to provideanti-inflammatory relief for dermatological irritations caused bypatches themselves, for example, as a result of sensitivity to theadhesive used or as a result of long-term use of occlusive products. Ina dermal or transdermal patch, the combination of the invention ispresent for its local or dermal action. Other active ingredients may bepresent for their systemic action in a transdermal patch or their localaction in a dermal patch. Thus, for example, the combination of theinvention can be included in nanospheres or microspheres incorporatedinto patches for smoking cessation treatment, e.g., nicotine patches,for treatment of cardiovascular conditions, e.g., nitroglycerin patches;for treatment of menopausal conditions, e.g., patches containing anestrogen such as estradiol, or an estrogen such as estradiol incombination with a progestin; vapor patches for treatment of congestionand related respiratory conditions; patches for treating asthma, such astulobuterol patches; patches for pain management containing analgesics;patches containing other dermatological agents such asantibacterials/antibiotics or antifungals; patches containingtestosterone or anti-anxiety agents or drugs for treating attentiondeficit disorder (ADD). The sustained/controlled release properties ofnanosphere or microsphere technology for the instant combinations canalso be advantageously utilized in conjunction with devices which needto be in continuous contact with the body, such as insulin pumps andcontinuous glucose monitors and ports, again to provideanti-inflammatory relief for the dermatological conditions which resultfrom long-term use of adhesive and/or occlusive products.Nanosphere/microsphere technology can also be used for sustaineddelivery (over a period of months or years) of the combination of theinvention from intravitreal implants, to reduce and/or inhibitinflammation of the retina and to thus treat retinopathy, or suchsustained delivery of the combination from cardiac stents to reduceand/or inhibit inflammation at their locus, Nanospheres may, by way ofexample only, range from 100 nm to 800 nm, while microspheres may beexemplified by ranges of 2 μm to 4 μm, or even 40 μm to 60 μm or 220 μmto 280 μm. Other technologies may of course be utilized to controldermal delivery of the instant combination.

The amount of active ingredient and enhancer in the compositionsaccording to the invention will vary with the precise compounds used,the type of formulation prepared and the particular condition for whichthe composition is to be administered. The formulation will generallycontain from about 0.0001 to about 5.0% by weight of the compound offormula (I). Topical preparations will generally contain 0.0001 to 2.5%,preferably 0.01 to 0.5% of active compound, and will be administeredonce daily, or as needed. The identity and amount of active compoundwill determine the amount of formula (II) compound utilized therewith,in keeping with the desired molar or weight ratios discussed above.Also, generally speaking, the compounds of formulas (I) and (II) can beincorporated into topical and other local compositions formulatedsubstantially as are such presently available types of compositionscontaining known glucocorticosteroids, with the amount of compound offormula (I) varying according to its potency.

The compositions of the invention may be formulated to include otheractive compounds known to be useful in combination withanti-inflammatory steroids, for example, antifungal, antibacterial,antibiotic and local anaesthetic agents, for example, clotrimazole,clioquinol (iodochlorhydroxyquin), iodoquinol, polymyxin B sulfate,neomycin sulfate, tobramycin, sulfacetamide sodium, gentamicin,thonzonium bromide, colistin sulfate and pramoxine hydrochloride. Thesteroids of formulas (I) and (II) may be combined with more than one ofthese additional active agents when appropriate, for example, with acombination of polymyxin B sulfate and neomycin sulfate.

The anti-inflammatory activity of the compounds of formula (I) iswell-known from the aforementioned Bodor U.S. Pat. No. 4,996,335 and thescientific literature; as noted earlier, one of these compounds,loteprednol etabonate, is currently marketed in the United States forophthalmic administration as an anti-inflammatory agent. The marketedAlrex® 0.2% sterile ophthalmic suspension is indicated for the temporaryrelief of signs and symptoms of seasonal allergic conjunctivitis whilethe marketed Lotomax® 0.5% sterile ophthalmic suspension is indicatedfor the treatment of steroid-responsive inflammatory conditions of thepalpebral and bulbar conjunctiva, cornea and anterior segment of theglobe such as allergic conjunctivitis, acne rosacea, superficialpunctate keratitis, herpes zoster keratitis, iritis, cyclitis, selectedinfective conjunctivitides, to reduce edema and inflammation. Lotomax®has more recently been found particularly useful in treating dry eyesyndrome. A third marketed product (Zylet®) is an ophthalmic suspensionof loteprednol etabonate 0.5% and tobramycin 0.3% and is indicated forsteroid-responsive inflammatory ocular conditions for which acorticosteroid is indicated and where superficial bacterial ocularinfection or risk thereof exists and where the inherent risk of steroiduse in certain infective conjunctivitides is accepted to obtain adiminution in edema and inflammation. The Zylet® combination has beenfound particularly useful in treating patients with blepharitis,bacterial conjunctivitis, peripheral ulcerative keratitis and oculartrauma. Other formulations for local administration for a variety ofconditions are in clinical trials.

The combination and compositions of the present invention areparticularly useful for treating the conditions for which the compoundof formula (I), especially loteprednol etabonate, has been found useful,for example, as Alrex®, Lotomax® and Zylet® compositions. Because of theenhancement afforded by the presence of the compound of formula (II),lower dosages of loteprednol etabonate can often be used to produce thesame or better results.

The combinations of the present invention have undergone humanvasoconstriction, or blanching, testing. Such testing gives a reliableindication of local anti-inflammatory/glucocorticoid activity. In thepresent case, it has been used to show that representative enhancingagents of formula (II) are inactive alone at the tested levels, that arepresentative compound of formula (I) is active alone at the testedlevels, and that administering a compound of formula (II) with acompound of formula (I) enhances the anti-inflammatory activity orduration of action or both of the representative formula (I) compound.

Human Vasoconstriction Testing Objective

The objective of this study is to evaluate the increasedvasoconstriction effects of loteprednol etabonate (LE) by hydrocortisone(HC) or prednisolone (PRN).

Methodology

Solutions of LE, HC and PRN (0.1 or 1 mM) alone, or mixtures of LE andHC (0.1+0.1 mM, or 1+1 mM), or LE and PRN (0.1+0.1 mM, or 1+1 mM) wereprepared with a vehicle containing absolute ethanol and propylene glycol(9:1). The resulting mixtures (20 μl) were loaded on the circular paperdisc (7 mm diameter), that were attached to a water impervious adhesivefilm (3M). After evaporation of ethanol (20 min), the films were appliedto the forearms of human volunteers for 4 hours. Subsequently, thevasoconstriction reaction was read and judged by the appearance ofpallor at various time intervals after the removal of the discs andfilms. The grading scale was as follows: 0, normal skin; 1, slightpallor; 2, pallor with at least two corners outlined; 3, even pallorwith a clear outlined of the application sites; 4, very intense pallor.Due to the relatively high variations in response between thevolunteers, a total score of 4 tests at each time point was taken forthe activity evaluation.

Results and Discussion

Human vasoconstriction test has been used as an index of percutaneousabsorption, activity and bioavailability of glucocorticoids. In thisstudy, the addition of HC, and PRN were investigated to evaluate theireffects on the activity of LE. Based on the previous findings, both HCand PRN are easily bound to transcortin receptors, and thepharmacological activity of corticosteroids was not correlated to thetranscortin bindings, the following hypothesis was established by theinventor: when applied together with LE, HC or PRN occupy thetranscortin receptor sites that are readily available to LE, resultingin more LE molecules bound to the glucocorticoid receptors, thusenhancing the local pharmacological activity of LE.

The results in the Table 3 and FIGS. 1 and 2 indicate that by itself, LEshowed good vasoconstriction activity, and both HC and PRN showed noactivity at the concentration range of 0.1 to 1 mM. The activity of LEwas greatly increased by addition, of the same amounts of HC or PRN(60-80% increase after co-administration of 0.1 mM, and 60-75% increaseafter co-administration of 1 mM). Since the vasoconstriction activity ofHC was 500 times less than (50 mM HC vs. 0.1 mM LE tested), and PRN was250 times less than (25 mM PRN vs. 0.1 mM LE tested) that of LE aspreviously reported, the increased vasoconstriction activity of LE by HCand PRN can be considered as due, not to the glucocorticoid receptorbindings of HC and PRN, but to the increased LE-glucocorticoid receptorbindings. These results have thus confirmed the hypothesis.

TABLE 3 Vasoconstriction activity (total score of 4 tests).^(1,2,3)Concentration Time after removal, hr mM 2 4 6 8 10 16 18 24 0.1 mM LE 23 5 5 3 1 1 1 LE + HC 3 7 9 8 8 3 2 2 LE + PRN 2 5 7 8 8 3 2 2 HC 0 0 00 0 0 0 0 PRN 0 0 0 0 0 0 0 0 1 mM LE 6 7 8 8 9 6 5 2 LE + HC 8 10 13 1313 10 8 4 LE + PRN 7 11 12 14 12 9 7 5 HC 0 0 0 0 0 0 0 0 PRN 0 0 0 0 00 0 0 ¹Compounds were dissolved in ethanol/propylene glycol (9/1)solution, and 20 μl of the mixtures were applied to circular patches (7mm diameter). The patches were applied to the forearms of the humanvolunteers, and covered with a water impervious film for 4 hours. Theintensity of vasoconstriction was judged at various time periods afterthe patches are removed. ²The grading scale was as follows: 0, normalskin; 1, slight pallor; 2, pallor with at least two corners outlined; 3,even pallor with a clear outlined of the application sites; 4, veryintense pallor. ³The total scores at each time period were taken due tothe large variations between the individual responses.

Conclusions

The results obtained indicate that the activity and duration of action,of a potent and CBG-binding steroid of formula (I) can be significantlyenhanced by the addition of another stronger CBG-bound, but lowerGR-activity steroid of formula (II) by affecting the concentration ofunbound steroid and the trans port-away processes.

The following Examples illustrate numerous formulations suitable foradministering the combinations of a compound of formula (I) and acompound of formula (II) to treat various kinds of local inflammatoryconditions. These formulations are merely illustrative and notlimitative of the remainder of the specification and claims in any waywhatsoever.

In these Examples, percentages are by weight unless otherwise noted.

EXAMPLE 1

A nasal suspension is prepared having the following composition:

NASAL SUSPENSION Loteprednol etabonate (LE) 0.5 to 1.0 g Hydrocortisone0.5 to 1.0 g (in 1:1 ratio to LE) Concentrated glycerin 2.6 gPolysorbate 80 0.2 g Microcrystalline cellulose carmellose sodium 2.0 to3.0 g Citric acid q.s. Benzalkonium chloride 0.005 g  Purified waterq.s. 100 g (pH 5.5)

The suspension can be prepared in accord with the procedure described inDoi U.S. Pat. No. 6,368,616 B1 of Apr. 9, 2002, incorporated byreference herein in its entirety and relied upon, except for theaddition of hydrocortisone, which can occur at the same time as theaddition of loteprednol etabonate.

Alternatively, from 0.1 to 0.5 g of hydrocortisone may be used insteadof the 0.5 to 1.0 g amount, listed above.

EXAMPLE 2

A nasal suspension is prepared having the following composition:

NASAL SUSPENSION Loteprednol etabonate 0.5 g Prednisolone 0.1 to 0.5 gPropylene glycol 2.0 g Polyoxyethylene hydrogenated castor oil 60 0.2 gMicrocrystalline cellulose carmellose sodium 3.0 g Phosphoric acid q.s.Benzethonium chloride 0.005 g Purified water q.s. 100 g (pH 5.5)

The suspension can be prepared in accord with, the procedure of theaforementioned '616 patent, except for the addition of prednisolone,which can occur at the same time as the addition of loteprednoletabonate.

The foregoing nasal formulations can be modified as described, in the'616 patent.

The following formulations can be prepared using routine productionprocedures for formulations of these types.

EXAMPLE 3

An eye drop suspension is prepared having the following composition:

EYE DROP SUSPENSION Loteprednol etabonate 0.5 g Prednisolone 0.1 to 0.5g ε-Aminocaproic acid 0.1 g Tyloxapol 0.3 g Polyvinylpyrrolidone(intrinsic viscosity = 30) 0.6 g Sodium edetate 0.01 g Benzalkoniumchloride (10 w/v %) 0.05 mL Hydrochloric acid q.s. Sterilized pure waterq.s 100 ml pH 5.53

0.05 to 0.1 mL of this suspension can be distilled into the eye 3 to 10times daily for the treatment of dry eye and other ophthalmicconditions. Alternatively, 0.2 g of loteprednol etabonate and 0.1 to 0.2g of prednisolone can be used in this suspension formulation for variousophthalmic conditions, including dry eye.

This suspension formulation can be modified as described in Inada et alU.S. Pat. No. 5,916,550, of Jun. 29, 1999, incorporated by referenceherein in its entirety and relied upon, except for the addition ofprednisolone at the time of loteprednol etabonate incorporation, toprovide other aqueous suspensions for use in the eye or nose which donot undergo pH depression even after prolonged storage.

EXAMPLE 4

An ointment is prepared having the following composition:

OINTMENT Compound of formula (I) e.g. loteprednol 0.20% w/w etabonateCompound of formula (II), e.g. prednisone 0.10 to 0.20% w/w Liquidparaffin 10.0% ww White soft paraffin 89.5% w/w

EXAMPLE 5

An aphthous ulcer pellet is prepared, having the following composition:

APHTHOUS ULCER PELLET Compound of formula (I), e.g. loteprednoletabonate 0.20 mg Compound of formula (II), e.g. corticosterone 0.05 to0.3 mg Lactose 69.0 mg Acacia 3.00 mg Magnesium stearate 0.75 mg

EXAMPLE 6

A retention enema is prepared having the following composition:

RETENTION ENEMA Compound of formula (I), e.g. loteprednol etabonate0.01% w/v Compound of formula. (II), e.g. hydrocortisone 0.01% w/v Tween80 0.05% w/v Ethanol 0.015% w/v Propylparaben 0.02% w/v Methylparaben0.08% w/v Distilled water q.s. 100 volumes

EXAMPLE 7

Eye drops are prepared having the following composition:

EYE DROPS Compound of formula (I), e.g. loteprednol 0.2% w/v etabonateCompound of formula (II), e.g. prednisolone 0.10 to 0.20% w/v acetateTween 80 2.5% w/v Ethanol 0.75% w/v Benzalkonium chloride 0.02% w/vPhenyl ethanol 0.25% w/v Sodium chloride 0.60% w/v Water for injectionq.s. 100 volumes

These eye drops are of particular use in the treatment of dry eyesyndrome as well as in the treatment of other various inflammatoryophthalmic conditions.

EXAMPLE 8

A dermal ointment is prepared having the following composition:

DERMAL OINTMENT Compound of formula (I), e.g. loteprednol etabonate 0.2%w/w Compound of formula (II), e.g. hydrocortisone 0.2% w/w LiquidParaffin 10.0% w/w White soft paraffin 88.8% w/w

An aphthous ulcer pellet is prepared having the following composition:

APHTHOUS ULCER PELLET Compound of formula (I), e.g. loteprednoletabonate 0.15 mg Compound of formula (II), e.g. hydrocortisone 0.5 to0.15 mg Lactose 60.25 mg Acacia 3.0 mg Magnesium sterate 0.75 mg

EXAMPLE 10

A retention enema is prepared having the following composition:

RETENTION ENEMA Compound of formula (I), e.g. loteprednol etabonate 0.1%w/v Compound of formula (II), e.g. hydrocortisone acetate 0.1% w/v Tween80 0.05% w/v Ethanol 0.015% w/v Propylparaben 0.02% w/v Methylparaben0.08% w/v Distilled water q.s. 100 volumes

EXAMPLE 11

Eye drops are prepared having the following composition:

EYE DROPS Compound of formula (I), e.g. loteprednol etabonate 0.2% w/vCompound of formula (II), e.g. prednisolone 0.1 to 0.2% w/v Tween 802.5% w/v Ethanol 0.75% w/v Benzalkonium chloride 0.02% w/v Phenylethanol 0.25% w/v Sodium chloride 0.60% w/v Water for injection q.s. 100volumes

These eye drops are of particular interest in the treatment of dry eyesyndrome.

EXAMPLE 12

Eye drops are prepared having the following composition:

EYE DROPS Compound of formula (I), e.g. loteprednol etabonate 0.5% w/vCompound of formula (II), e.g. hydrocortisone 0.2 to 0.5% w/v Povidone0.6% w/v Benzalkonium chloride 0.02% w/v Sodium edetate U.S.P. 0.10% w/vGlycerin U.S.P. 2.5% w/v Tyloxapol U.S.P. 3.0% w/v Sodium chloride 0.3%w/v Sodium γ-aminobutyrate 1.0% w/v Sterile distilled water q.s. 100volumes

The ingredients listed above are combined, then the pH is checked and,if necessary, adjusted to 5.0-5.5 by basifying with sodium hydroxide oracidifying with hydrochloric acid.

These eye drops are useful in the treatment of dry eye syndrome.

Alternatively, 0.2% w/v of loteprednol etabonate and 0.1 to 0.2% w/vhydrocortisone or other compound of formula (II) can be used in thissuspension formulation for various ophthalmic conditions, including dryeye.

EXAMPLE 13

An eye drop preparation especially adapted for treatment of dry eye isprepared as follows:

Phase I Carbopol 934P NF (acrylic acid-based polymer) 0.25 g PurifiedWater 99.75 g Phase II Propylene Glycol 5.0 g EDTA 0.1 mg LoteprednolEtabonate 20 to 50 g Hydrocortisone or Prednisolone 20 to 50 g, in 1:1ratio with loteprednol etabonate Cyclosporine 5.0 g

Five parts of Phase II are mixed with 20 parts of Phase I for 15minutes, then the pH is adjusted to 6.2-6.4 using IN NaOH.

EXAMPLE 14

Povidone 1.00% w/w HAP (30%) 0.05% w/w Glycerin 3.00% w/w PropyleneGlycol 3.00% w/w Loteprednol Etabonate (LE) 0.20-0.50% w/wHydrocortisone or Prednisolone 0.20-0.50% w/w or other compound offormula (II) (in 1:1 ratio to LE) Cyclosporine 0.10% w/w Tyloxapol 0.25%w/w Alexidine 2 HCl 1-2 ppm

This formulation is especially useful in the treatment of dry eye.

EXAMPLE 15

Povidone 1.50% w/w HAP (30%) 0.05% w/w Glycerin 3.00% w/w PropyleneGlycol 3.00% w/w Loteprednol Etabonate (LE) 0.20-0.5% w/w (Compound offormula (II), e.g. 0.20-0.5% w/w Hydrocortisone or Prednisolone (in 1:1ratio to LE) Cyclosporine 0.10% w/w Tyloxapol 0.25% w/w Alexidine 2HCl1-2 ppm

This formulation is designed for dry eye treatment

Yet other compositions of the invention can be conveniently formulatedusing known techniques

Thus, for example, an inhalation formulation suitable for use in thetreatment of asthma can be prepared as a metered-dose aerosol unitcontaining a representative compound of formula (I) such as loteprednoletabonate and a representative compound of formula (II) such ashydrocortisone, prednisolone, prednisone or corticosterone, according toprocedures well-known to those skilled in the art of pharmaceuticalformulations. Such an aerosol unit may contain a microcrystallinesuspension of loteprednol etabonate and one of the aforementionedcompounds of formula (II) in a (II):(I) weight ratio of from 0.5:1 or0.2:1 to 1:1 in suitable propellants (e.g. trichlorofluoromethane anddichlorodifluoromethane and dichlorotetrafluoroethane), with oleic acid,sorbitan trioleate or other suitable dispersing agent. Each unittypically contains 1-10 milligrams of the aforesaid loteprednoletabonate, approximately 5-50 micrograms of which are increased at eachactuation

Another example of a pharmaceutical composition according to theinvention is a foam suitable for treatment of a wide variety ofinflammatory anorectal disorders, to be applied anally or perianally,comprising 0.1% or 0.5% of a compound of formula (I) such, asloteprednol etabonate and 0.05% or 0.5%, respectively, of hydrocortisoneor prednisolone, and 1% of a local anaesthetic such as pramoxinehydrochloride, in a mucoadhesive foam base of propylene glycol,ethoxylated stearyl alcohol, polyoxyethylene-10-stearyl ether, cetylalcohol, methyl paraben, propyl paraben, triethanolamine, and water,with inert propellants. Alternatively, 0.2% or 1.0%) of hydrocortisoneor prednisolone may be employed

Yet another pharmaceutical formulation according to the invention is asolution or suspension suitable for use as a retention enema, a singledose of which typically contains 40-80 milligrams of a compound offormula (I) such as loteprednol etabonate and from 0.1 to 1 times thatamount of a compound of formula (II), preferably hydrocortisone orprednisolone, together with sodium chloride, polysorbate 80 and 1 to 6ounces of water (the water being added shortly before use). Thesuspension can be administered as a retention enema or by continuousdrip several times weekly in the treatment of ulcerative colitis.

Another exemplary formulation is a sterile, multiple dose antibiotic andsteroid combination suspension for topical ophthalmic use. Each mL ofsuspension contains: as active ingredients, tobramycin 0.3% (3 mg) andloteprednol etabonate 0.5% (5 mg); as synergist, hydrocortisone 0.1 to0.5% (1 to 5 mg); as preservative, benzalkonium chloride 0.01%; and asinactives tyloxapol, edetate disodium, sodium chloride, hydroxyethylcellulose, sodium sulfate, sulfuric acid and/or sodium hydroxide (toadjust pH) and purified water.

Another example of an antibiotic/steroid combination for topicalophthalmic use contains 0.5% loteprednol etabonate, 0.1 to 0.5%hydrocortisone or prednisolone, and 0.3% tobramycin together withedatate disodium, glycerin, povidone, purified water, tyloxapol and0.01% benzalkonium chloride as preservative. Each mL contains 5 mgloteprednol etabonate, 1-5 mg hydrocortisone or prednisolone and 3 mgtobramycin. Sulfuric acid and/or sodium hydroxide may be added to adjustthe pH to 5.7 to 5.9 and achieve isotonicity.

Another example is a sterile, multiple dose antibiotic and steroidcombination ointment for topical ophthalmic use. Each gram of ointmentcontains: as active ingredients, tobramycin 0.3% (3 mg) and loteprednoletabonate 0.2% (0.2 mg); as synergist, prednisolone acetate 0.05% to0.1% (0.5 to 1 mg); as preservative, chlorobutanol 0.5%; and asinactives, mineral oil and white petrolatum.

Yet another exemplary formulation is an ophthalmicanti-infective/anti-inflammatory sterile suspension containing: asactive ingredients, sulfacetamide sodium 10% and loteprednol etabonate(microfine suspension) 0.5%; as synergist, prednisone 0.1 to 0.2%; aspreservative, benzalkonium chloride (0.004%); as inactives, polyvinylalcohol 1.4%, polysorbate 80, edetate disodium, dibasic sodiumphosphate, monobasic potassium phosphate, sodium thiosulfate,hydrochloric acid and/or sodium hydroxide to adjust the pH, and purifiedwater. A similar composition may be formulated for otic administration.

Another ophthalmic ointment containing an antibacterial and acorticosteroid is exemplified by a sterile ointment containing: asactives, sulfacetamide sodium 10% and loteprednol etabonate, 0.2%; assynergist, hydrocortisone, 0.05% to 0.2%; as preservative,phenylmercuric acetate (0.0008%); and as inactives, mineral oil, whitepetrolatum, and petrolatum and lanolin alcohol.

Another example of a sterile ophthalmic formulation is a topicalanti-inflammatory/anti-infective suspension containing, as activeingredients, loteprednol etabonate (microfine suspension) 0.5%, neomycinsulfate equivalent to 0.35% neomycin base, polymyxin B sulfate 10,000units/mL; as synergist, prednisone, 0.10 to 0.5%; as preservative,thimerosal 0.001%; and as inactive ingredients, polyvinyl alcohol 1.4%),polysorbate 80, propylene glycol, sodium acetate and purified water.

Yet another illustrative sterile ophthalmic suspension which is atopical anti-inflammatory/anti-infective combination product contains:as active ingredients, gentamicin sulfate equivalent to 0.3% gentamicinbase and loteprednol etabonate (microfine suspension) 0.5%); assynergist, corticosterone, 0.2 to 0.5%; as preservative, benzalkoniumchloride 0.005%; as inactive ingredients, polyvinyl alcohol 1.4%,edetate disodium, hydroxypropyl methylcellulose, polysorbate 80, sodiumcitrate dihydrate, sodium chloride and purified, water. The compositionmay contain sodium hydroxide and/or hydrochloric acid to adjust the pHto be in the range of 5.5 to 6.6.

The antibiotic/steroid ophthalmic compositions described above,particularly those in which the antibiotic is tobramycin, are idealcombinations for treating patients with ocular trauma and patientsrequiring control of both inflammation and infection, such as those withblepharitis, bacterial conjunctivitis and peripheral ulcerativekeratitis. The antibiotic/steroid combination of the invention istypically administered four times daily over the course of two weeks forblepharitis; then, patients are maintained on formulations of theinvention which do not contain the antibiotic, administered lessfrequently (for example from twice per day to once per week).

Another sterile ophthalmic suspension formulation contains, per mL: asactive, loteprednol etabonate 2 mg (0.2%); as synergist,11-deoxyhydrocortisone 0.1 to 0.2 mg; as preservative, benzalkoniumchloride 0.01%; as inactives, edetate disodium, glycerin, povidone,purified water and tyloxapol. Hydrochloric acid and/or sodium hydroxidemay be added to adjust, the pH to 5.3 to 5.6. Among other ophthalmicuses, treatment of dry eye syndrome can utilize this suspensionformulation.

Yet another sterile ophthalmic suspension formulation contains, per mL:as active ingredient, loteprednol etabonate 5 mg (0.5%); as synergist,hydrocortisone acetate 0.1 to 0.5 mg; as preservative, benzalkoniumchloride 0.01%; as inactive ingredients, edetate disodium, glycerine,povidone, purified water and tyloxapol Hydrochloric acid and/or sodiumhydroxide may be added to adjust the pH to 5.3 to 5.6. Again, such asuspension is of use in treating dry eye syndrome.

For dermatological use, in the treatment of fungal infections withassociated inflammation, a cream or lotion combining clotrimazole, asynthetic antifungal agent, a compound of formula (I) and a compound offormula (II) may be formulated. A suitable cream, or lotion contains, ineach gram of cream or lotion: 10 mg of clotrimazole, 0.5 mg ofloteprednol etabonate and 0.1 to 0.5 mg of hydrocortisone, in ahydrophilic cream or lotion base consisting of purified water, mineraloil, white petrolatum, cetearyl alcohol 70/30, ceteareth-30, propyleneglycol, sodium phosphate monobasic monohydrate and phosphoric acid, withbenzyl alcohol as a preservative. If necessary, the lotion may containsodium hydroxide.

Capsules or tablets suitable for oral administration in the treatment ofCrohn's disease may be formulated to protect the compounds of formulas(I) and (II) from gastric juice and to dissolve when they reach a higherpH in the duodenum. In one formulation of this type, each capsulecontains 5-20 mg of micronized loteprednol etabonate, 2-10 mg ofmicronized hydrocortisone, with ethyl cellulose, acetyl tributylcitrate, methacrylic acid copolymer type C, triethyl citrate, anti foam.M, polysorbate 80, talc and sugar spheres, in a shell composed ofgelatin, iron oxide and titanium oxide. The granules in the formulationare coated to prevent dissolution in gastric juice but dissolve atpH>5.5, normally when the granules reach the duodenum. After that, amatrix of ethyl cellulose with the steroids releases them in atime-dependent manner in the intestinal lumen.

For the treatment of asthma, a sterile suspension for oral inhalationvia a compressed air-driven jet nebulizer may be formulated. Thesuspension contains, as the active ingredient, micronized loteprednoletabonate; as the enhancing agent, micronized hydrocortisone orhydrocortisone acetate (in a 0.2:1 to 1:1 weight ratio to loteprednoletabonate); and as inactives, disodium edetate, sodium chloride, sodiumcitrate, citric acid, polysorbate 80, and water for injection. Singledose ampules contain 0.5, 1.0, 1.5 and 2.0 mg of loteprednol etabonate.

An alternate preparation for the treatment of asthma is aninhalation-driven multidose dry powder inhaler containing onlymicronized loteprednol etabonate and micronized hydrocortisone. Eachactuation is designed to provide 400 meg of loteprednol etabonate andabout 250 meg of hydrocortisone and to act directly on the respiratorytract.

For the treatment and management of nasal symptoms of seasonal orperennial allergic rhinitis, a nasal spray or gel may be used. One suchnasal foundation is a metered-dose, manual pump spray containing amicronized suspension of loteprednol etabonate and hydrocortisoneacetate in an aqueous medium. The medium also contains microcrystallinecellulose and carboxymethyl cellulose sodium, anhydrous dextrose,polysorbate 80, disodium edetate, potassium sorbate and purified water,with hydrochloric acid added to adjust the pH to about 4.5. Theformulation is designed to deliver 50 or 100 meg of loteprednoletabonate and 25-100 meg, respectively, of hydrocortisone acetate perspray.

To treat the pruritic and inflammatory manifestations ofanti-inflammatory steroid-responsive dermatoses, especially localizedlesions which are dry and scaly, a tape containing the active ingredientand enhancer may be used as both a vehicle and an occlusive dressing.One such product is a moisture-impervious plastic surgical tapecontaining loteprednol etabonate and hydrocortisone. Each squarecentimeter of tape contains 10 μg of loteprednol etabonate and 2 to 5 μgof hydrocortisone evenly distributed in the adhesive layer. The tape ismade of polyethylene film, while the adhesive is a synthetic copolymerof acrylate ester and acrylic acid.

For the treatment of ulcerative colitis, a rectal suspension in adisposable single-dose enema may be formulated for readyself-administration. A typical disposable single dose unit for rectaladministration contains 60 mL of suspension containing: 10-100 mg ofloteprednol etabonate and 5-100 mg of hydrocortisone (in a 0.5:1 or 1:1weight ratio to loteprednol etabonate) in air aqueous solutioncontaining car bonier 934P, polysorbate 80, purified water, sodiumhydroxide and methyl paraben

For the treatment of superficial bacterial infections of the externalauditory canal and treatment of infections of mastoidectomy andfenestration cavities accompanied by inflammation, an otic suspensionmay be used. One such suspension contains colistin sulfate and neomycinsulfate as antibiotics, the selected steroids of formulas (I) and (II)and thonzonium bromide, a surface-active agent; for example, asuspension which contains, per mL: colistin base activity, 3 mg (as thesulfate); neomycin base activity, 3.3 mg (as the sulfate); loteprednoletabonate, 10 mg (1%); hydrocortisone, 2 to 10 mg (0.2 to 1%),thonzonium bromide, 0.5 mg (0.5%), polysorbate 80, acetic acid andsodium acetate in a buffered aqueous vehicle. Thimerosal (0.002%) isadded as a preservative. The suspension is buffered at pH 5.

A foam may be formulated for use in the treatment of inflammatory andpruritic manifestations of corticosteroid-responsive dermatoses of theanal region. An exemplary foam contains 1% loteprednol etabonate, 0.2 to1% hydrocortisone, and 1% pramoxine hydrochloride (a local anaesthetic)in a hydrophilic base containing cetyl alcohol, emulsifying wax, methyl,paraben, polyoxyethylene-10 stearyl ether, propylene glycol, propylparaben, purified water; trolamine, isobutene and propane.

For intramuscular, intrasynovial, soft tissue or intralesional injectionfor various conditions, especially for intrasynovial or soft, tissueinjection as therapy in synovitis of osteoarthritis, rheumatoidarthritis, acute and subacute bursitis, acute gouty arthritis,epicondylitis, acute nonspecific tenosynovitis and post-traumaticosteoarthritis, a sterile aqueous suspension may be formulated. Each mLof suspension contains 20, 40 or 80 mg/mL of loteprednol etabonate; and10, 20 or 40 or 20, 40 or 80 mg/mL, respectively, of hydrocortisone orhydrocortisone acetate, respectively; together with polyethylene glycol3350, polysorbate 80, monobasic sodium phosphate, dibasic sodiumphospate USP, benzyl, alcohol (as preservative), sodium chloride (toadjust tonicity) and when necessary to adjust pH to within 3.5 to 7.0,sodium hydroxide and/or hydrochloric acid

For use in the treatment of in (lamed hemorrhoids, post irradiationproctitis, as an adjunct in the treatment of chronic ulcerative colitis,cryptitis, other inflammatory conditions of the anorectum and pruritusani, suppositories may be formulated. One such suppository contains10-25 mg loteprednol etabonate and 10-25 hydrocortisone (in a 1:1 weightratio to the loteprednol etabonate) in a hydrogenated cocoglyceridebase.

For relief of the inflammatory and pruritic manifestations ofcorticosteroid-responsive dermatoses of the anal region, a rectal creammay be used. An illustrative rectal cream contains 1% loteprednoletabonate, 1% hydrocortisone and 1% pramoxine hydrochloride (a topicalanaesthetic) in a washable, nongreasy base containing stearic acid,cetyl alcohol, aquaphor, isopropyl palmitate, polyoxyl 40 stearate,propylene glycol, potassium sorbate 0.1%, sorbic acid 0.1%,triethanolamine, lauryl sulfate and water.

For various dermal conditions having both an inflammatory/pruriticcomponent, and a fungal/bacterial component, a topical cream compositionmay be formulated to contain a compound of formula (I), a compound offormula (II) and iodoquinol (as an antifungal and antibacterial agent).An illustrative cream contains, per gram, 10 mg of loteprednoletabonate, 2 to 10 mg of hydrocortisone and 10 mg of iodoquinol in agreaseless base of purified water, propylene glycol, glycerylmonostearate SE, cholesterol and related sterols, isopropyl myristate,polysorbate 60, cetyl alcohol, sorbitan monostearate, polyoxyl 40stearate, sorbic acid and polysorbate 20.

Another topical preparation for dermatological use in treatingconditions with an inflammatory/pruritic component and afungal/bacterial component may be formulated to contain a compound offormula (I), a compound of formula (II) and iodochlorhydroxyquin (alsoknown as clioquinol), which has antifungal and antibacterial properties.These ingredients are, for example, formulated as a cream, ointment orlotion containing 3% iodochlorhydroxyquin, 0.5% or 1.0% loteprednoletabonate and 0.2 to 1.0% prednisolone acetate.

Dry eye, also known genetically as keratoconjunctivitis sicca (KCS), isa common opthalmological disorder affecting millions of Americans eachyear. The condition is particularly widespread among post-menopausalwomen due to hormonal changes following the cessation of fertility. Dryeye may afflict an individual with varying severity. In mild cases, apatient may experience burning, a feeling of dryness, and persistentirritation such as is often caused by small bodies lodging between theeye lid and the eye surface. In severe cases, vision may besubstantially impaired. Other diseases, such as Sjogren's disease,manifest dry eye complications.

The human ocular surface is normally covered by a tear film that iscomposed of a superficial thin lipid layer (primarily derived frommeibomian gland secretions), a middle bulk aqueous layer (consisting ofproteins, electrolytes, and water secreted by lacrimal glands), and theinnermost mucus layer derived from mucins secreted by the ocular surfaceepithelial cells.

A stable tear film ensures comfort and serves as the refractive opticalsurface of the eye. Furthermore, the tear film serves as a barrier forthe ocular surface against microbial infection and inflammation frommechanical trauma. Tear film deficiencies, referred to as dry eye, are acommon clinical problem that can result from decreased secretion oftears by the lacrimal gland and/or increased evaporative loss due to adeficient lipid layer or blink abnormalities. Patients with mild dry eyecomplain of annoying eye irritations. Those with severe dry eye, such asSjogren's syndrome, may experience constant and disabling eyeirritation, and develop ocular surface epithelial disease andsight-threatening sterile or microbial corneal ulceration.

Corticosteroids are potent, non-specific anti-inflammatory drugs thatinhibit a variety of chemotactic substances and factors that mediatecapillary permeability, contraction of nonvascular smooth muscle, andvasodilatation. In addition, corticosteroids suppress inflammation byinhibiting edema, fibrin deposition, migration of leukocytes andphagocytic activity.

Topical corticosteroids are useful in a variety of ophthalmic conditionsand are generally indicated for treatment of steroid-responsiveinflammatory conditions of the palpebral and bulbar conjunctiva, corneaand anterior segment of the eye. Although corticosteroids are widelyused as a topical agent for ocular inflammation, most possess a safetyrisk profile that limits their more general utility. A common riskassociated with corticosteroid therapy is an elevation of intraocularpressure (IOP). In addition, chronic use of topical corticosteroids mayresult in the development of cataracts. The compounds of formula (I),and specifically loteprednol etabonate, are compounds designed assite-active corticosteroids that will undergo a predictabletransformation to inactive metabolites. The relatively rapid metabolismof loteprednol etabonate to an inactive metabolite improves the safetyprofile of this corticosteroid. This characteristic of Lotemax®(loteprednol etabonate ophthalmic suspension, 0.5%) makes it anexcellent candidate for use in inflammatory ocular conditions. Thecompositions and combinations of the present invention are likewiseexcellent candidates for treatment of such conditions in view of thepresence of a compound of formula (I), such as loteprednol etabonate,therein.

For years it has been recognized that patients with dry eye developpathologic changes of the ocular surface epithelial cells termedsquamous metaplasia. Unreported research, suggests that this process isthe result of increased proliferation, abnormal differentiation, andinflammation of the ocular surface epithelial cells. In contrast tonormal cells, these metaplastic cells do not produce the mucus thatnormally coats the ocular surface and forms a barrier against infectionand mechanical trauma. This renders the ocular surface susceptible todamage from the mild trauma of desiccation, blinking, rubbing, andforeign bodies (such as contact lenses).

Lotemax® (loteprednol etabonate ophthalmic suspension, 0.5%) wasapproved by the FDA in March of 1998 for use in the treatment of steroidresponsive conditions. Researchers have concluded that there is aninflammatory etiology in some, if not most, cases of dry eye. Reports ofclinical studies have supported the use of topical corticosteroidsolutions in the treatment of patients with keratoconjunctivitis sicca.Stephen Pflugfelder, MD, introduced the diagnostic test of fluoresceintear clearance to further differentiate and select patients with dry eyewith an inflammatory component. It is postulated that the reduced flowof tears through the tear film and out of the cul-de-sac into thenaso-lacrimal duct results in stasis, which allows inflammatorymediators in the tear film to remain in contact with the mucosa of theconjunctiva and the corneal epithelium. Stasis, thus, may increase theinflammation associated with the KCS. This process may also beresponsible for a further reduction of tear production in such patients.

Basic and clinical research performed over the past decade and moreindicates that inflammation develops on the ocular surface as tearproduction and tear clearance decrease. Immunopathological changes havebeen observed in the conjunctiva of patients with dry eye includingincreased expression of immune activation and cellular adhesionmolecules (e.g. HLA-DR antigen and ICAM-1) as well as infiltration ofthe epithelium and stroma by inflammatory cells. Increased levels ofpro-inflammatory cytokines such as, IL-1, IL-6 and TNF-α, have beendetected in the tear fluid and conjunctival epithelium of patients withdry eye. The fear fluid concentration of IL-1α was found to increase astear clearance decreased. Significantly increased concentration andactivity of matrix metalloproteinase-9 (MMP-9) has been detected in thetear fluid of dry eye patients with delayed tear clearance. Productionof MMP-9 by corneal epithelial cells and leukocytes is stimulated by thepro-inflammatory cytokines IL-1 and TNF-α Experimental evidence suggeststhat MMP-9 is involved in the pathogenesis of keratoconjunctivitis siccaby dissolving the tight junction proteins that anchor the differentiatedmucin-bearing apical corneal epithelial cells. Glucocorticosteroids arerecognized for their ability to decrease the production ofpro-inflammatory cytokines and matrix metalloproteinase enzymes. Severalrecent clinical studies have supported the use of topical corticosteroidsolutions in the treatment of patients with keratoconjunctivitis sicca

The following recent patents or publications are noted:

U.S., Pat. No. 6,153,607 discloses a preservative-free formulationcontaining an effective amount of a corticosteroid in an aqueous carrierto treat a dry eye condition. The formulation may be provided as a part,of a therapeutic regimen to treat a variety of dry eye conditions andocular surface disorders manifesting delayed tear clearance previouslynot readily treatable. The formulation may be packaged as containers ofsingle dosage amounts of the corticosteroid-aqueous formulationsufficient for pulsed-therapy of acute exacerbations of the irritationsymptoms anti ocular surface disease of conditions associated with dryeye and delayed tear clearance.

U.S. Patent Application Publication No. 2003/0008853 discloses22,29-epoxy-3,4,6,7,29-pentahydroxy-,(3α,4β,5α,6α,-7β,14β,22S)-stigmastan-15-oneas useful for treating dry eye disorders and other disorders requiringthe wetting of the eye. This publication further notes thatcorticosteroids, such as prednisolone, dexamethasone, fluoromethalone,hydrocortisone, loteprednol, triamcinolone, etc., cannot be used forprolonged therapy in dry eye patients without causing side effects. Thispublication further notes that steroid-related complications includingincreased intraocular pressure and cataract formation have been observedin dry eye patients treated with corticosteroids after several months oftherapy. Therefore, it was surprisingly discovered that a topicalophthalmic formulation containing Loteprednol etabonate, when used forfour weeks, was efficacious and well tolerated in the management ofpatients with KCS with inflammation. Moreover, a differential treatmenteffect, which was in some cases significant, was seen in subsets ofpatients who presented a moderate to severe inflammatory componentcorresponding with more severe KCS. This has been further elaboratedupon in Meyerling U.S. Patent Appln. Publication No. 2005/0182039 ofAug. 18, 2005 directed to use of loteprednol etabonate for the treatmentof dry eye and Bartels U.S. Patent Appln. Publication No. 2005/0222110,of Oct. 6, 2005 directed to treating moderate to severe dry eye withloteprednol etabonate, both incorporated by reference herein in theirentireties and relied upon. Further, Xia et al. U.S. Patent Appln.Publication No. 2006/0148686 of Jul. 6, 2006, describes ophthalmiccompositions and methods of treating dry eye wherein the compositionadministered is a corticosteroid, preferably loteprednol etabonate, andcyclosporin, especially Cyclosporin A; the Xia et. al. patentpublication is also incorporated by reference herein in its entirety andrelied upon. Other methods and combination products for treating dry eyewith corticosteroids, especially with loteprednol etabonate, aredescribed in Gamache et al. U.S. Patent Appln, Publication No.2006/0069075, published Mar. 30, 2006 (loteprednol etabonate with aMUC-1 secretagogue such as an HETE, derivative) and Chappell et al. U.S.Patent Appln. Publication No, 2007/0105761 (loteprednol etabonate with anon-steroidal immunophilin-dependent immunosuppressant), both of whichare also incorporated by reference herein in their entireties and reliedupon.

Therefore, disclosed in embodiments herein is a method of treating dryeye, including moderate to severe dry eye, in patients who present aninflammatory component, especially a moderate to severe inflammatorycomponent. Symptoms of severe dry eye may include, among others,conjunctival injection (hyperemia), such as bulbar conjunctivalhyperemia, inferior tarsal conjunctival hyperemia, nasal bulbarconjunctival hyperemia; lid margin hyperemia, central corneal stainingand redness of the eye. The present method comprises topicallyadministering to the patient with dry eye, especially moderate to severedry eye, a combination of a compound of formula (I) and a compound offormula (II) as defined hereinabove, or a composition comprising saidcombination and an opthalmologically acceptable carrier, especially whenthe compound of formula (I) is loteprednol etabonate. In another aspect,the present invention provides compositions comprising a combination ofa compound of formula (I), preferably loteprednol etabonate, and acompound of formula (II), together with cyclosporin, especiallycyclosporin A, and an opthalmologically acceptable carrier. Suchcompositions of the invention are as discussed in detail hereinabove,except that they additionally contain cyclosporin (as disclosed forloteprednol etabonate itself by Xia et al US 2006/0148686).Alternatively, the compositions of the present invention containing (I)and (II) can be modified to include a MUC-1 secretaogue such as an HETEderivative [especially 15(S) HETE] as described by Gamache et al. US2006/0069075 for use with loteprednol etabonate or a non-steroidalimmunophilin dependent immunosuppressant as described by Chappell et al.US 2007/0105761 for use with loteprednol etabonate. Such compositionsare useful in the methods of treating dry eye herein.

The present invention also contemplate methods of treating dry eye whichcomprise concomitantly administering the combination of compounds (I)and (II) according to the present invention with one of the additionalagents mentioned in the preceding paragraph; although it is highlyconvenient, to place (I), (II) and the additional agent in a singledosage form, there may be instances in which separate administration isdesired.

According to one method of tire present invention for treating dry eye,a formulation comprising a compound of formula (I), especiallyloteprednol etabonate, and a compound of formula (II) and apharmaceutically acceptable carrier for topical ophthalmicadministration or implantation into the conjunctival sac or anteriorchamber of the eye is administered to a mammal in need thereof. Theformulations are formulated in accordance with methods known in the artfor the particular route of administration desired.

The formulations administered according to the present invention for dryeye treatment comprise a pharmaceutically effective amount of compoundof formula (I), e.g. loteprednol etabonate. As used herein, a“pharmaceutically effective amount” is one which is sufficient to reduceor eliminate signs or symptoms of dry eye. Generally, for formulationsintended to be administered topically to the eye in the form of eyedrops or eye ointments, the amount of loteprednol etabonate will beabout 0.001 to 5.0% (w/w). For preferred topically administrableophthalmic formulations, the amount of loteprednol etabonate will beabout 0.001 to 1.0% (w/w). Because of the presence of thecompound/enhancer of formula (II), the amount of loteprednol etabonatecan be considerably less than that required if the formula (II) compoundwere absent. For example, an amount of 0.2% w/w loteprednol etabonatetogether with an enhancer of formula (II) may afford results similar to0.5% w/w loteprednol etabonate without the enhancer.

The formulations administered to treat dry eye according to the presentinvention may also include various other ingredients, including but notlimited to surfactants, tonicity agents, buffers, preservatives,co-solvents and viscosity building agents.

Surfactants that can be used are surface-active agents that areacceptable for ophthalmic or otolaryngological uses. Useful surfaceactive agents include but are not limited to polysorbate 80, tyloxapol,TWEEN 80 (ICI America Inc., Wilmington, Del.), PLURONIC F-68 (from BASF,Ludwigshafen, Germany) and the poloxamer surfactants can also be used.These surfactants are nonionic alkaline oxide condensates of an organiccompound which contains hydroxyl groups. The concentration in which thesurface active agent may be used is only limited by neutralization ofthe bactericidal effects on the accompanying preservatives (it present),or by concentrations which may cause irritation.

Various tonicity agents may be employed to adjust, the tonicity of tireformulation. For example, sodium chloride, potassium chloride, magnesiumchloride, calcium chloride, nonionic diols, preferably glycerol,dextrose and/or mannitol may be added to the formulation to approximatephysiological tonicity. Such an amount of tonicity agent will vary,depending on the particular agent to be added. In general, however, theformulations will have a tonicity agent in an amount sufficient to causethe final formulation to have an ophthalmically acceptable osmolality(generally about 150-450 mOsm)

An appropriate buffer system (e.g., sodium phosphate, sodium acetate,sodium citrate, sodium borate or boric acid) may be added to theformulations to prevent pH drift under storage conditions. Theparticular concentration will vary, depending on the agent employed.

Topical ophthalmic products are typically packaged in multidose form.Preservatives are thus required to prevent microbial contaminationduring use. Suitable preservatives include: benzalkonium chloride,chlorobutanol, benzododecinium bromide, methyl paraben, propyl paraben,phenylethyl alcohol, edetate disodium, sorbic acid, polyquaternium-1, orother agents known to those skilled in the art. Such preservatives aretypically employed at a level of from 0.001 to 1.0% w/w Unit doseformulations of the present invention will be sterile, but typicallyunpreserved. Such formulations, therefore, generally will not containpreservatives

Co-solvents and viscosity building agents may be added to theformulations to improve the characteristics of the formulations. Suchmaterials can include nonionic water-soluble polymer. Other compoundsdesigned to lubricate, “wet,” approximate the consistency of endogenoustears, aid in natural tear build-up, or otherwise provide temporaryrelief of dry eye symptoms and conditions upon ocular administration tothe eye are known in the art. Such compounds may enhance the viscosityof the formulation, and include, but are not limited to: monomericpolyols, such as, glycerol, propylene glycol, ethylene glycol; polymericpolyols, such as, polyethylene glycol, hydroxypropylmethyl cellulose(“HPMC”), carboxy methylcellulose sodium, hydroxy propylcellulose(“HPC”), dextrans, such as, dextran 70; water soluble proteins, such asgelatin; and vinyl polymers, such as, polyvinyl alcohol,polyvinylpyrrolidone, povidone and carbomers, such as, carbomer 934P,carbomer 941, carbomer 940 and carbomer 974P. Other compounds may alsobe added to the ophthalmic formulations of the present invention toincrease the viscosity of the carrier. Examples of viscosity enhancingagents include, but are not limited to: polysaccharides, such ashyaluronic acid and its salts, chondroitin sulfate and its salts,dextrans, various polymers of the cellulose family; vinyl polymers; andacrylic acid polymers.

Formulations formulated for the treatment of dry eye-type diseases anddisorders may also comprise aqueous carriers designed to provideimmediate, short-term relief of dry eye-type conditions. Such carrierscan be formulated as a phospholipid carrier or an artificial tearscarrier, or mixtures of both. As used herein, “phospholipid carrier” and“artificial tears carrier” refer to aqueous formulations which: (i)comprise one or more phospholipids (in the case of phospholipidcarriers) or other compounds, which lubricate, “wet,” approximate theconsistency of endogenous tears, aid in natural tear build-up, orotherwise provide temporary relief of dry eye symptoms and conditionsupon ocular administration; (ii) are safe; and (iii) provide theappropriate delivery vehicle for the topical administration of aneffective amount of loteprednol etabonate and its enhancing agent.Examples of artificial tears formulations useful as artificial fearscarriers include, but are not limited to, commercial products, such asMoisture Eyes™ Lubricant Eye Drops/Artificial Tears, Moisture Eyes™Liquid Gel lubricant eye drops, Moisture Eyes™ Preservative FreeLubricant Eye props/Artificial Tears and Moisture Eyes™ Liquid GelPreservative Free Lubricant Eye props/Artificial Tears (Bausch & LombIncorporated, Rochester, N.Y.), Examples of phospholipid carrierformulations include those disclosed in U.S. Pat. No. 4,804,539 (Guo etal.), U.S. Pat. No. 4,883,658 (Holly), U.S. Pat. No. 4,914,088 (Glonek),U.S. Pat. No. 5,075,104 (Gressel et al.), U.S. Pat. No. 5,278,151 (Korbet al.), U.S. Pat. No. 5,294,607 (Glonek et al.), U.S. Pat. No.5,371,108 (Korb et al), U.S. Pat. No. 5,578,586 (Glonek et al), thecontents of each of which are incorporated by reference herein.

Formulations formulated for the treatment of dry eye-type diseases anddisorders may be prepared as ophthalmic ointments. Ointments are wellknown ophthalmic formulations and are essentially an oil-based deliveryvehicle. Typical ointments use petroleum and/or lanolin base to which isadded the active ingredient, usually as 0.1 to 2%, and excipients.Common bases include mineral oil, petrolatum and combinations thereof,but oil bases are not limited thereto.

The preferred formulations of the present invention are intended foradministration to a human or veterinary patient suffering from dry eyeor symptoms of dry eye. Preferably, such formulations will beadministered topically. In general, the doses used for the abovedescribed purposes will vary, but will be in an effective amount toeliminate or improve dry eye conditions. Generally, 1-2 drops of suchformulations will be administered from once to many times per day. Theformulation can be provided as a package for the treatment of dry eye;the package would then include the pharmaceutical formulation comprisingloteprednol etabonate and formula (II) compound contained in apharmaceutically acceptable container; a written package insertcontaining instructions for using the formulation for the treatment ofdry eye; and outer packaging identifying the pharmaceutical formulationcontained therein. In certain embodiments wherein the formulation ispreservative lice, the package would contain a pharmaceuticallyacceptable container suitable for single use by a user of the packagedformulation. In such embodiments it is envisioned that the outerpackaging would contain at least one pharmaceutically acceptablecontainer containing the loteprednol etabonate and compound (II)formulation. Preferably the outer packing would contain a multiplicityof single use containers, for example, enough single use containers toprovide for a one-month supply of the formulation.

The methods of treating dry eye in accord, with the present inventionare of particular interest in treating moderate to severe dry eye, mostespecially when it is associated with refractive surgery. Ideally,administration is carried out for a period of greater than one month andmay even be continued for a period of greater than three year in lightof studies noted in Bartels US 2005/0222110, as well as in light, of thefact that the compound of formula (II) is present in a subtherapeuticamount and therefore would not suffer from the dangers of long-term useof the formula (II) compounds in therapeutic amounts.

As noted hereinabove, cortienic acid, the corresponding Δ^(1,4) acid,and their simple alkyl esters have been previously described asenhancing the anti-inflammatory activity and duration of action ofloteprednol and related soft steroids in Bodor United States PatentApplication Publication No 2005/0026892, published Feb. 3, 2005,incorporated by reference herein in its entirety and relied upon. Asfurther indicated hereinabove, such inactive metabolites have also beendescribed as enhancing the anti-inflammatory activity and duration ofaction of selected other corticosteroids, for example, hydrocortisone;see Bodor United States Patent Application Publication No. 2005/0020551A1, published Jan. 2, 2005, likewise incorporated by reference herein inits entirety and relied upon. The thus-enhanced combinations andcompositions incorporating the inactive metabolite enhancing agents arehighly useful in the treatment of dry eye, especially moderate to severedry eye, most especially when the active agent is loteprednol etabonate.Again, the presence of the enhancing agent may allow comparable resultswith less active agent, i.e. 0.2% loteprednol etabonate plus cortienicacid or its methyl or ethyl ester or Δ¹-cortienic acid or its methyl orethyl ester is expected to be approximately as effective in treating dryeye as 0.5% loteprednol etabonate alone. The enhanced combinations,compositions and methods of Bodor US 2005/0020551 are also useful in thetreatment of dry eye, especially moderate to severe dry eye. Further,the inactive metabolite-enhanced combinations, compositions and methodsof Bodor US 2005/0026892 and the enhanced combinations and compositionsand methods of Bodor US 2005/0020551 can be modified to additionallycontain/administer cyclosporin, a MUC-1 secretagogue such as an HETEderivative or a non-steroidal immunophilin-dependent immunosuppresant totreat dry eye, as described in detail hereinabove for the combinations,compositions and methods of the present invention.

While the invention has been described in terms of various preferredembodiments, the skilled artisan will appreciate that variousmodifications, substitutions, omissions and changes may be made withoutdeparting from the spirit thereof. Accordingly, if is intended that thescope of the present invention be limited solely by the scope of thefollowing claims, including equivalents thereof.

1. A method for enhancing the anti-inflammatory activity or duration ofaction, or both, of a compound having the formula:

wherein: R₁ is C₁-C₇ alkyl; Z is carbonyl or β-hydroxymethylene; X is Clor E; and the dotted line in ring A indicates that the 1,2-linkage issaturated or unsaturated; following ophthalmic administration of saidcompound to a warm-blooded animal in need of treatment to alleviate dryeye, said method comprising ophthalmically co-administering saidcompound to said animal with a synergistically effective amount of acompound having the formula:

wherein: Z₁ is carbonyl, β-hydroxymethylene or methylene; R₂ is H, —OHor —OCOR₃ wherein is C₁-C₅ alkyl; Y is —OH, —SH or OCOR₄, wherein R₄ isC₁-C₅ alkyl, cyclopentylethyl or diethylaminomethyl; and the dotted lineis defined as above; the amount of compound of formula (II) beingsufficient to enhance the anti-inflammatory activity or duration ofaction, or both, of said compound of formula (I).
 2. A method accordingto Claim 1, wherein the compound of formula (I) is: (a) chloromethyl17α-ethoxycarbonyloxy-11β-hydroxyandrosta-1,4-dien-3-one-17β-carboxylate;(b) chloromethyl11β-hydroxy-17α-methoxycarbonyloxyandrost-4-en-3-one-17β-carboxylate;(c) chloromethyl17α-ethoxycarbonyloxy-11β-hydroxyandrost-4-en-3-one-17β-carboxylate; (d)chloromethyl17α-butoxycarbonyloxy-11β-hydroxyandrost-4-en-3-one-17β-carboxylate; (e)chloromethyl11β-hydroxy-17α-isopropoxycarbonyloxyandrost-4-en-3-one-17β-carcarboxylate; (f) chloromethyl11β-hydroxy-17α-isopropoxycarbonyloxyandrosta-1,4-dien-3-one-17β-carboxylate;(g)chloromethyl-11β-hydroxy-17α-isobutoxycarbonyloxyandrost-4-en-3-one-17β-carboxylate;(h) chloromethyl11β-hydroxy-17α-propoxycarbonyloxyandrost-4-en-3-one-17β-carboxylate;(i) fluoromethyl11β-hydroxy-17α-isopropoxycarbonyloxyandrost-4-en-3-one-17β-carcarboxylate; (j) chloromethyl11β-hydroxy-17α-n-propoxycarbonyloxyandrosta-1,4-dien-3-one-17β-carboxylate;or (k) chloromethyl11β-hydroxy-17α-methoxycarbonyloxyandrosta-1,4-dien-3-one-17β-carboxylate.3. A method according to Claim 1, wherein the compound of formula (I) isloteprednol etabonate.
 4. A method according to Claim 1, wherein thecompound of formula (II) is cortisone, cortisone acetate,hydrocortisone, hydrocortisone acetate, hydrocortisone aceponate,hydrocortisone butyrate, cortisone 21-cyclopentanepropionate,hydrocortisone 21-cypionate, hydrocortisone valerate, prednisolone,prednisolone acetate, prednisolone tebutate, prednisolone 21-pivalate,prednisolamate, prednival, prednisone, prednisone 21-acetate,corticosterone, tixocortol, corticosterone 21-acetate, hydrocortamate,11-deoxycorticosterone, 11-deoxyhydrocortisone, prednicarbate orhydrocortisone tebutate.
 5. A method according to Claim 1, wherein themolar ratio of compound of formula (II) to compound of formula (I) isfrom about 2:1 to about 0.05:1.
 6. A method for enhancing theanti-inflammatory activity or duration of action, or both, ofloteprednol etabonate following ophthalmic administration thereof to awarm-blooded animal in need of treatment to alleviate dry eye, saidmethod comprising ophthalmically co-administering loteprednol etabonateto said animal with a synergistically effective amount, of a compoundhaving the formula:

wherein Z₁ is carbonyl, β-hydroxymethyl or methylene; R₂ is H, —OH or—OCOR₃ wherein R₃ is C₁-C₅ alkyl; Y is —OH, —SH or —OCOR₄ wherein R₄ isC₁-C₅ alkyl; and the dotted line in ring A indicates that the1,2-linkage is saturated or unsaturated; the amount of compound offormula (II) being sufficient to enhance the anti-inflammatory activityor duration of action, or both, of loteprednol etabonate.
 7. A methodaccording to Claim 6, wherein the compound of formula (II) is cortisone,cortisone acetate, hydrocortisone, hydrocortisone acetate,hydrocortisone aceponate, hydrocortisone butyrate, hydrocortisonevalerate, prednisolone, prednisolone acetate, prednisolone tebutate,prednisolone 21-pivalate, prednival, prednisone, prednisone 21-acetate,corticosterone, tixocortol, corticosterone 21-acetate,11-deoxycorticosterone, 11-deoxyhydrocortisone, prednicarbate orhydrocortisone tebutate.
 8. A method according to Claim 7, wherein themolar ratio of compound of formula (II) to loteprednol etabonate is fromabout 2:1 to about 0.05:1.
 9. A method according to Claim 7, wherein theanimal is in need of treatment to alleviate moderate to severe dry eye.10. A method, for alleviating dry eye in a warm-blooded animalexhibiting same, said method comprising administering to the eye or eyesof said animal a combination comprising: (a) a compound having theformula:

wherein: R₁ is C₁-C₇ alkyl; Z is carbonyl or β-hydroxymethylene; X is Clor F; and the dotted line in ring A indicates that the 1,2-linkage issaturated or unsaturated; and (b) a compound having the formula:

wherein: Z₁ is carbonyl, β-hydroxymethylene or methylene; R₂ is H, —OHor —OCOR₃ wherein R₃ is C₁-C₅ alkyl; Y is —OH, —SH or —OCOR₄, wherein R₄is C₁-C₅alkyl, cyclopentylethyl or diethylaminomethyl; and the dottedline is defined as above; in a combined synergistic anti-inflammatoryeffective amount; the amount of compound of formula (II) beingsufficient to enhance the anti-inflammatory activity or duration ofaction, or both, of said compound of formula (I), said amount of saidcompound of formula (II) being insufficient alone to haveanti-inflammatory activity.
 11. A method according to Claim 10, whereinthe compound of formula (I) is loteprednol etabonate.
 12. A methodaccording to claim 11, wherein the compound of formula (II) iscortisone, cortisone acetate, hydrocortisone, hydrocortisone acetate,hydrocortisone aceponate, hydrocortisone butylate, cortisone21-cyclopentanepropionate, hydrocortisone 21-cypionate, hydrocortisonevalerate, prednisolone, prednisolone acetate, prednisolone tebutate,prednisolone 21-pivalate, prednisolamate, prednival, prednisone,prednisone 21-acetate, corticosteroid, tixocortol, corticosteroid21-acetate, hydrocortamate, 11-deoxycorticosterone,11-deoxyhydrocortisone, prednicarbate or hydrocortisone tebutate.
 13. Amethod according to Claim 10, wherein the animal is in need of treatmentto alleviate moderate to severe dry eye.
 14. A method for alleviatingdry eye in a warm-blooded animal exhibiting same, said method comprisingadministering to the eye or eyes of said animal a pharmaceuticalcomposition comprising: (1) a combined synergistic anti-inflammatoryeffective amount of: (a) a compound having the formula:

wherein: R₁ is C₁-C₇ alkyl; Z is carbonyl or β-hydroxymethylene; X is Clor F; and the dotted line in ring A indicates that the 1,2-linkage issaturated or unsaturated; and (b) a compound having the formula:

wherein: Z₁ is carbonyl, β-hydroxymethylene or methylene; R₂ is H, —OHor —OCOR₃ wherein R₃ is C₁-C₅ alkyl; Y is —OH, —SH or —OCOR₄, wherein R₄is C₁-C₅ alkyl, cyclopentylethyl or diethylaminomethyl; and the dottedline is defined as above; the amount of compound of formula (II) beingsufficient to enhance the anti-inflammatory activity or duration ofaction, or both, of said compound of formula (I), said amount of saidcompound of formula (II) being insufficient alone to haveanti-inflammatory activity; and (2) a non-toxic, pharmaceuticallyacceptable carrier therefor suitable for ophthalmic application.
 15. Amethod according to Claim 14, wherein the compound of formula (I) isloteprednol etabonate.
 16. A method according to Claim 15, wherein thecompound of formula (II) is cortisone, cortisone acetate,hydrocortisone, hydrocortisone acetate, hydrocortisone aceponate,hydrocortisone butyrate, cortisone 21-cyclopentanepropionate,hydrocortisone 21-cypionate, hydrocortisone valerate, prednisolone,prednisolone acetate, prednisolone tebutate, prednisolone 21-pivalate,prednisolamate, prednival, prednisone, prednisone 21-acetate,corticosteroid, tixocortol, corticosterone 21-acetate, hydrocortamate,11-deoxycorticosterone, 11-deoxyhydrocortisone, prednicarbate orhydrocortisone tebutate.
 17. A method to Claim 16, wherein the compoundof formula (II) is hydrocortisone, hydrocortisone acetate,hydrocortisone butyrate, prednisolone, prednisolone acetate, prednisone,corticosteroid, 11-deoxycorticosterone or 11-deoxyhydrocortisone.
 18. Amethod for alleviating dry eye in a warm-blooded animal exhibiting same,said method comprising administering to the eye or eyes of said animal apharmaceutical composition comprising: (1) a combined synergisticanti-inflammatory effective amount of: (a) loteprednol etabonate; and(b) a compound having the formula:

wherein Z₁ is carbonyl, β-hydroxymethylene or methylene; R₂ is H, —OH or—OCOR₃ wherein R₃ is C₁-C₅ alkyl; Y is —OH, —SH or —OCOR₄ wherein R₄ isC₁-C₅ alkyl and the dolled line in ring A indicates that the 1,2-linkageis saturated or unsaturated, the amount of compound of formula (II)being sufficient to enhance the anti-inflammatory activity or durationof action, or both, of loteprednol etabonate, said amount of saidcompound of formula (II) being insufficient alone to haveanti-inflammatory activity; and (2) a non-toxic, pharmaceuticallyacceptable carrier therefor suitable for ophthalmic application.
 19. Amethod according to Claim 18, wherein the molar ratio of compound offormula (II) to loteprednol etabonate is from about 2:1 to about 0.05:120. A method according to Claim 18, wherein the animal has moderate tosevere dry eye.
 21. A method according to Claim 18, wherein the animalis treated for a period of greater than one month
 22. A method accordingto Claim 21 wherein the treatment is for a period of greater than threeyears.
 23. A method according to Claim 14, wherein the compositionfurther comprises cyclosporin.
 24. A method according to Claim 18,wherein the composition further comprises cyclosporin
 25. A methodaccording to Claim 18, wherein the composition further comprises a MUC-1secretagogue or a non-steroidal immunophilin-dependentimmunosuppressant.
 26. A pharmaceutical composition comprising: (1) acombined synergistic anti-inflammatory effective amount of: (a) acompound having the formula:

wherein: R₁ is C₁-C₇ alkyl; Z is carbonyl or β-hydroxymethylene; X is Clor F; and the dotted line in ring A indicates that the 1,2-linkage issaturated or unsaturated; and (b) a compound having the formula:

wherein: Z₁ is carbonyl, β-hydroxymethylene or methylene; R₂ is H, —OHor —OCOR₃ wherein R₃ is C₁-C₅ alkyl; Y is —OH, —SH or —OCOR₄, wherein R₄is C₁-C₅ alkyl, cyclopentylethyl or diethylaminomethyl; and the dottedline is defined as above; the amount of compound of formula (II) beingsufficient to enhance the anti-inflammatory activity or duration ofaction, or both, of said compound of formula (I), said amount of saidcompound of formula (II) being insufficient alone to haveanti-inflammatory activity; (2) cyclosporin; and (3) a non-toxic,pharmaceutically acceptable carrier therefor suitable for ophthalmicapplication.
 27. A composition according to Claim 26, wherein thecompound of formula (I) is loteprednol etabonate.
 28. A compositionaccording to Claim 26, wherein the compound of formula (II) iscortisone, cortisone acetate, hydrocortisone, hydrocortisone acetate,hydrocortisone aceponate, hydrocortisone butyrate, cortisone21-cyclopentanepropionate, hydrocortisone 21-cypionate, hydrocortisonevalerate, prednisolone, prednisolone acetate, prednisolone tebutate,prednisolone 21-pivalate, prednisolamate, prednival, prednisone,prednisone 21-acetate, corticosteroid, tixocortol, corticosterone21-acetate, hydrocortamate, 11-deoxycorticosterone,11-deoxyhydrocortisone, prednicarbate or hydrocortisone tebutate.
 29. Apharmaceutical composition comprising: (1) a combined synergisticanti-inflammatory effective amount of: (a) loteprednol etabonate; and(b) a compound having the formula:

wherein Z₁ is carbonyl, β-hydroxymethylene or methylene; R₂ is H, —OH or—OCOR₃ wherein R₃ is C₁-C₅ alkyl; Y is —OH, —SH or —OCOR₄ wherein R₄ isC₁-C₅ alkyl; and the dotted line in ring A indicates that the1,2-linkage is saturated or unsaturated, the amount of compound offormula (II) being sufficient to enhance the anti-inflammatory activityor duration of action, or both, of loteprednol etabonate, said amount ofsaid compound of formula (II) being insufficient alone to haveanti-inflammatory activity; and (2) cyclosporin; and (3) a non-toxic,pharmaceutically acceptable carrier therefor suitable for ophthalmicapplication.
 30. A composition according to Claim 22, wherein the molarratio of compound of formula (II) to loteprednol etabonate is from about2:1 to about 0.05:1.